Healthcare Provider Details

I. General information

NPI: 1396672945
Provider Name (Legal Business Name): JEFFREY VAN JACKSON II
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2026
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3121 W BROAD ST
COLUMBUS OH
43204-1306
US

IV. Provider business mailing address

3121 W BROAD ST
COLUMBUS OH
43204-1306
US

V. Phone/Fax

Practice location:
  • Phone: 614-869-2002
  • Fax: 614-792-6240
Mailing address:
  • Phone: 614-607-0769
  • Fax: 614-792-6240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.195931
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: