MEDICARE: JACKOSKY HEALTH INC

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	2084P0804X	Child & Adolescent Psychiatry Physician	35075326	OH

General Provider Information

NPI Number	:	1841506763
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACKOSKY HEALTH INC

Provider Business Mailing Address
First Line	:	30400 DETROIT RD STE 404
Second Line	:
City	:	WESTLAKE
State	:	OH
Zip	:	44145-1855
Country	:	US
Telephone Number	:	440-250-2130
Fax Number	:	440-250-2140

Provider Business Practice Location Address
First Line	:	30400 DETROIT RD STE 404
Second Line	:
City	:	WESTLAKE
State	:	OH
Zip	:	44145-1855
Country	:	US
Telephone Number	:	440-250-2130
Fax Number	:	440-250-2140

Authorized Official
Title or Position	:	OWNER
Name	:	CATHERINE JACKOSKY
Credential	:	M.D.
Telephone Number	:	440-250-2130

Provider Enumeration Date	:	08/30/2010
Last Update Date	:	08/30/2010

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