Healthcare Provider Details

I. General information

NPI: 1518080811
Provider Name (Legal Business Name): DERRICK O'NEAL JACKSON DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 04/05/2022
Certification Date: 04/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 OAK HILL AVENUE
YOUNGSTOWN OH
44502-1415
US

IV. Provider business mailing address

3255 E LIVINGSTON AVENUE
COLUMBUS OH
43227-1967
US

V. Phone/Fax

Practice location:
  • Phone: 330-870-3900
  • Fax: 330-870-3901
Mailing address:
  • Phone: 866-953-3519
  • Fax: 614-239-1080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number30003456
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code213ER0200X
TaxonomyRadiology Podiatrist
License Number36003456
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number36003456
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: