Healthcare Provider Details

I. General information

NPI: 1912981945
Provider Name (Legal Business Name): THEODORE MICHAEL JACKSON D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2005
Last Update Date: 02/21/2023
Certification Date: 02/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 W 12TH AVE
COLUMBUS OH
43210-1267
US

IV. Provider business mailing address

1254 N HIGH ST APT 307
COLUMBUS OH
43201-2438
US

V. Phone/Fax

Practice location:
  • Phone: 614-247-6590
  • Fax:
Mailing address:
  • Phone: 618-616-5324
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number19026503
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number30.026788
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: