Provider Demographics
NPI:1093474272
Name:JACKSON, WILLIAM JR
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:
Last Name:JACKSON
Suffix:JR
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:P.O.BOX 37247
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:OH
Mailing Address - Zip Code:44146-9998
Mailing Address - Country:US
Mailing Address - Phone:216-214-8907
Mailing Address - Fax:
Practice Address - Street 1:720 LINCOLN BLVD
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:OH
Practice Address - Zip Code:44146-3730
Practice Address - Country:US
Practice Address - Phone:216-214-8907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-15
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171W00000X, 172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
No171W00000XOther Service ProvidersContractor