Healthcare Provider Details

I. General information

NPI: 1194560979
Provider Name (Legal Business Name): ISAIAH JACKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2024
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 METROHEALTH DR
CLEVELAND OH
44109-1900
US

IV. Provider business mailing address

2500 METROHEALTH DR
CLEVELAND OH
44109-1900
US

V. Phone/Fax

Practice location:
  • Phone: 216-778-4428
  • Fax:
Mailing address:
  • Phone: 216-778-4428
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN.CNP.0043563
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: