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General NPI Number Information
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NPI Number | 1699832709
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Entity Type | Individual
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Provider Name | BENITA MARIE JACKSON MD
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Gender | Female
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Dates
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Enumeration Date | 01/02/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 7252 TUMBLEBROOK DR
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City | NEW ALBANY
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State | OH
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Zip | 43054-8891
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Country | US
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Telephone | 614-933-0095
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Fax |
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Provider Business Mailing Address
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Address Line | 7252 TUMBLEBROOK DR
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City | NEW ALBANY
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State | OH
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Zip | 43054-8891
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Country | US
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Telephone | 614-933-0095
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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 | 2083P0901X
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Taxonomy Name | Public Health & General Preventive Medicine Physician
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License Number | 35-061647
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License Number State | OH
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