Healthcare Provider Details

I. General information

NPI: 1699609180
Provider Name (Legal Business Name): TERRENCE JACKSON
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2026
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

434 FOREST AVE
CINCINNATI OH
45229-2516
US

IV. Provider business mailing address

434 FOREST AVE
CINCINNATI OH
45229-2516
US

V. Phone/Fax

Practice location:
  • Phone: 513-667-3654
  • Fax:
Mailing address:
  • Phone: 513-667-3654
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: