Healthcare Provider Details

I. General information

NPI: 1902244312
Provider Name (Legal Business Name): JEREMY JACKSON D.O., M.P.H.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2013
Last Update Date: 10/06/2022
Certification Date: 10/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 W GRAND AVE
DAYTON OH
45405-4720
US

IV. Provider business mailing address

1391 FINGER LKS
DAYTON OH
45458-3121
US

V. Phone/Fax

Practice location:
  • Phone: 937-723-3567
  • Fax: 937-723-5017
Mailing address:
  • Phone: 740-505-3022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number02005405A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number011603
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: