MEDICARE: JEFFREY VAN JACKSON II

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	CDCA.195931	OH

General Provider Information

NPI Number	:	1396672945
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEFFREY VAN JACKSON II

Provider Business Mailing Address
First Line	:	3121 W BROAD ST
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43204-1306
Country	:	US
Telephone Number	:	614-607-0769
Fax Number	:	614-792-6240

Provider Business Practice Location Address
First Line	:	3121 W BROAD ST
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43204-1306
Country	:	US
Telephone Number	:	614-869-2002
Fax Number	:	614-792-6240

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/07/2026
Last Update Date	:	05/07/2026

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