Healthcare Provider Details

I. General information

NPI: 1699797043
Provider Name (Legal Business Name): MARYANN JACKO DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 DICKSON ST
WELLINGTON OH
44090-1364
US

IV. Provider business mailing address

217 DICKSON ST
WELLINGTON OH
44090-1364
US

V. Phone/Fax

Practice location:
  • Phone: 440-647-2752
  • Fax: 440-647-1241
Mailing address:
  • Phone: 440-647-2752
  • Fax: 440-647-1241

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number21302
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: