MEDICARE: EKAETE JACKSON MD

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	207Q00000X	Family Medicine Physician	35-123871	OH

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	9338635	OTHER	OH	PARTNERS PHYSICIAN GROUP MEDICARE GROUP #

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	1841239274	OTHER	OH	PARTNERS PHYSICIAN GROUP TYPE 2 NPI #
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1437382306
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EKAETE JACKSON MD

Provider Business Mailing Address
First Line	:	754 S CLEVELAND AVE
Second Line	:	#300
City	:	MOGADORE
State	:	OH
Zip	:	44260-2200
Country	:	US
Telephone Number	:	330-628-2686
Fax Number	:	330-628-0828

Provider Business Practice Location Address
First Line	:	754 S CLEVELAND AVE
Second Line	:	#300
City	:	MOGADORE
State	:	OH
Zip	:	44260-2200
Country	:	US
Telephone Number	:	330-628-2686
Fax Number	:	330-628-0828

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

Provider Enumeration Date	:	08/26/2009
Last Update Date	:	12/04/2014

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Directions to “ EKAETE JACKSON MD” Practice Location

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