MEDICARE: KEITH 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
1	122300000X	Dentist	30023286	OH

General Provider Information

NPI Number	:	1831404938
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEITH JACKSON

Provider Business Mailing Address
First Line	:	7113 MIAMI AVE
Second Line	:
City	:	MADEIRA
State	:	OH
Zip	:	45243-2616
Country	:	US
Telephone Number	:	513-561-5318
Fax Number	:	513-561-1120

Provider Business Practice Location Address
First Line	:	7113 MIAMI AVE
Second Line	:
City	:	MADEIRA
State	:	OH
Zip	:	45243-2616
Country	:	US
Telephone Number	:	513-561-5318
Fax Number	:	513-561-1120

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

Provider Enumeration Date	:	08/12/2010
Last Update Date	:	08/12/2010

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Directions to “ KEITH JACKSON ” Practice Location

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