Healthcare Provider Details

I. General information

NPI: 1467134544
Provider Name (Legal Business Name): TERRANCE LAMONT JACKSON SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2023
Last Update Date: 08/07/2023
Certification Date: 08/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2155 GEORGETOWN RD NE
CANTON OH
44704-2257
US

IV. Provider business mailing address

2155 GEORGETOWN RD NE
CANTON OH
44704-2257
US

V. Phone/Fax

Practice location:
  • Phone: 816-377-7225
  • Fax:
Mailing address:
  • Phone: 816-377-7225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: