Healthcare Provider Details

I. General information

NPI: 1669337093
Provider Name (Legal Business Name): DEJA JACKSON
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2025
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5555 SMITH RD
BROOKPARK OH
44142-2028
US

IV. Provider business mailing address

5555 SMITH RD
BROOKPARK OH
44142-2028
US

V. Phone/Fax

Practice location:
  • Phone: 216-453-1112
  • Fax:
Mailing address:
  • Phone: 216-453-1112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: