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General NPI Number Information
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NPI Number | 1255143061
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Entity Type | Individual
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Provider Name | PHILLIP A JACKSON SR.
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Gender | Male
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Dates
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Enumeration Date | 01/21/2025
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Last Update Date | 01/21/2025
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Provider Practice Location Address
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Address Line | 237 HILLSIDE CIR APT 1
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City | MANSFIELD
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State | OH
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Zip | 44907-1763
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Country | US
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Telephone | 614-886-8392
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Fax |
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Provider Business Mailing Address
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Address Line | 237 HILLSIDE CIR APT 1
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City | MANSFIELD
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State | OH
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Zip | 44907-1763
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Country | US
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Telephone | 614-886-8392
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174H00000X
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Taxonomy Name | Health Educator
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License Number |
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License Number State |
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