Healthcare Provider Details

I. General information

NPI: 1619719895
Provider Name (Legal Business Name): SARAH MURTHA JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2024
Last Update Date: 06/26/2024
Certification Date: 06/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3567 RESERVE COMMONS DR
MEDINA OH
44256-5323
US

IV. Provider business mailing address

329 WYOGA LAKE BLVD
CUYAHOGA FALLS OH
44224-1109
US

V. Phone/Fax

Practice location:
  • Phone: 330-536-3746
  • Fax:
Mailing address:
  • Phone: 440-387-3640
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.466805
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN.CNP.0036855
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: