Provider Demographics
NPI:1033714845
Name:JACKSON, EDWARD CHARLES
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:CHARLES
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38358 US 36 PO BOX 82
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:OH
Mailing Address - Zip Code:43844
Mailing Address - Country:US
Mailing Address - Phone:740-824-3615
Mailing Address - Fax:
Practice Address - Street 1:38358 US 36
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:OH
Practice Address - Zip Code:43844
Practice Address - Country:US
Practice Address - Phone:740-824-3615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2821343Medicaid