Healthcare Provider Details

I. General information

NPI: 1295799112
Provider Name (Legal Business Name): ROBERT J JACKSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2006
Last Update Date: 06/30/2022
Certification Date: 06/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 SIXTH STREET SW OHIO HOSPITAL BASED PHYSICIAN CORP
CANTON OH
44710
US

IV. Provider business mailing address

PO BOX 80690
CANTON OH
44708-0690
US

V. Phone/Fax

Practice location:
  • Phone: 330-363-7462
  • Fax: 330-363-7679
Mailing address:
  • Phone: 330-363-7444
  • Fax: 330-363-7770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCOA01766NA
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: