MEDICARE: DR. THEODORE MICHAEL JACKSON D.M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	19026503	IL
2	122300000X	Dentist	30.026788	OH

General Provider Information

NPI Number	:	1912981945
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THEODORE MICHAEL JACKSON D.M.D.

Provider Business Mailing Address
First Line	:	1254 N HIGH ST APT 307
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43201-2438
Country	:	US
Telephone Number	:	618-616-5324
Fax Number	:

Provider Business Practice Location Address
First Line	:	305 W 12TH AVE
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43210-1267
Country	:	US
Telephone Number	:	614-247-6590
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/02/2005
Last Update Date	:	02/21/2023

Similar Medicare Providers

1962933788 — MOHAMMED ISMAIL D.O.
Practice Location Address:

395 W 12TH AVE
COLUMBUS, OH
43210-1267

Practice Phone: 614-293-8315
Practice Fax: 614-293-6935

1891086286 — NICHOLAS DAVID ROMANO MD
Practice Location Address:

395 W 12TH AVE
COLUMBUS, OH
43210-1267

Practice Phone: 614-293-8315
Practice Fax: 614-293-6935

1679568422 — DR. MICHAEL CHARLES BARROWS M.D.
Practice Location Address:

395 W 12TH AVE FL 4
COLUMBUS, OH
43210-1267

Practice Phone: 614-293-8315
Practice Fax:

1700875010 — GEORGE PATRICK CAIN MD
Practice Location Address:

395 W 12TH AVE , RM 460
COLUMBUS, OH
43210-1267

Practice Phone: 614-293-8299
Practice Fax: 614-293-6935

1891774022 — GRETCHEN G. CORDERO MD
Practice Location Address:

395 W 12TH AVE
COLUMBUS, OH
43210-1267

Practice Phone: 614-293-8315
Practice Fax: 614-293-6935

1386624047 — DARICK L JACOBS M.D.
Practice Location Address:

395 W 12TH AVE RM 460
COLUMBUS, OH
43210-1267

Practice Phone: 614-293-8315
Practice Fax: 614-293-6935

Directions to “ DR. THEODORE MICHAEL JACKSON D.M.D.” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

Copyright © 2007-2025 (Powered by Swiss Vault Engine), all rights reserved. HIPAA liability, trademark, document use and software licensing rules apply. All registered trademarks, used in the content, are the property of their owners. Your interactions with this site are in accordance with our Terms of Use and Privacy Policy.