Healthcare Provider Details

I. General information

NPI: 1306605274
Provider Name (Legal Business Name): MR. JACKSON SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2024
Last Update Date: 05/17/2026
Certification Date: 05/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8809B CINCINNATI DAYTON RD
WEST CHESTER OH
45069-3134
US

IV. Provider business mailing address

8809B CINCINNATI DAYTON RD
WEST CHESTER OH
45069-3134
US

V. Phone/Fax

Practice location:
  • Phone: 513-360-8205
  • Fax:
Mailing address:
  • Phone: 513-360-8205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC.2405746
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: