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NPI Code Detail

MEDICARE: ALICE O JACKSON

MEDICARE: ALICE O JACKSON
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
1171M00000XCase Manager/Care Coordinator
2374J00000XDoulaOH

General Provider Information

NPI Number : 1568143949
Entity Type Code : Individual
Provider Name (Legal Business Name) : ALICE O JACKSON
Provider Business Mailing Address
First Line : 17325 EUCLID AVE
Second Line :
City : CLEVELAND
State : OH
Zip : 44112-1247
Country : US
Telephone Number : 216-202-3381
Fax Number : 216-202-3767
Provider Business Practice Location Address
First Line : 3043 SUPERIOR AVE E
Second Line :
City : CLEVELAND
State : OH
Zip : 44114-4349
Country : US
Telephone Number : 216-307-1538
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/27/2023
Last Update Date : 03/18/2026

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