Healthcare Provider Details

I. General information

NPI: 1104304450
Provider Name (Legal Business Name): CLARENCE A JACKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2018
Last Update Date: 07/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8440 MARKET ST
YOUNGSTOWN OH
44512-6703
US

IV. Provider business mailing address

8440 MARKET ST
YOUNGSTOWN OH
44512-6703
US

V. Phone/Fax

Practice location:
  • Phone: 330-965-9999
  • Fax: 330-757-0000
Mailing address:
  • Phone: 330-965-9999
  • Fax: 330-757-0000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number0000000
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: