Healthcare Provider Details

I. General information

NPI: 1831208768
Provider Name (Legal Business Name): CARL E. JACKSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 05/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

386 MEDWAY RD
HIGHLAND HEIGHTS OH
44143-3734
US

IV. Provider business mailing address

386 MEDWAY RD
HIGHLAND HEIGHTS OH
44143-3734
US

V. Phone/Fax

Practice location:
  • Phone: 440-953-1898
  • Fax: 440-460-0749
Mailing address:
  • Phone: 440-953-1898
  • Fax: 440-460-0749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number35057489
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: