Healthcare Provider Details

I. General information

NPI: 1225965965
Provider Name (Legal Business Name): RANDY JACKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2026
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 MONTANA AVE STE 245
CINCINNATI OH
45211-3829
US

IV. Provider business mailing address

2300 MONTANA AVE STE 245
CINCINNATI OH
45211-3829
US

V. Phone/Fax

Practice location:
  • Phone: 513-978-1451
  • Fax:
Mailing address:
  • Phone: 513-978-1451
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: