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NPI Code Detail

MEDICARE: MR. ULYSSES D JACKSON III

MEDICARE: MR. ULYSSES D JACKSON III
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
1101YA0400XAddiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number : 1942835467
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. ULYSSES D JACKSON III
Provider Business Mailing Address
First Line : 205 WADSWORTH RD
Second Line :
City : WADSWORTH
State : OH
Zip : 44281-9580
Country : US
Telephone Number : 330-564-5445
Fax Number :
Provider Business Practice Location Address
First Line : 205 WADSWORTH RD
Second Line :
City : WADSWORTH
State : OH
Zip : 44281-9580
Country : US
Telephone Number : 234-217-8882
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/04/2020
Last Update Date : 11/27/2023

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