Healthcare Provider Details

I. General information

NPI: 1457598054
Provider Name (Legal Business Name): RICHARD ALLEN JACKSON RN,CRNFA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2009
Last Update Date: 01/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 EUCLID AVE
CLEVELAND OH
44195-0001
US

IV. Provider business mailing address

9500 EUCLID AVE
CLEVELAND OH
44195-0001
US

V. Phone/Fax

Practice location:
  • Phone: 216-444-4393
  • Fax:
Mailing address:
  • Phone: 216-444-4393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License NumberRN191497
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: