Provider Demographics
NPI:1104034008
Name:JACKSON, HEATHER MARIA (DO)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:MARIA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 SMITH RD
Mailing Address - Street 2:STE A
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45212-2787
Mailing Address - Country:US
Mailing Address - Phone:513-533-1199
Mailing Address - Fax:513-533-6000
Practice Address - Street 1:2322 LAKEVIEW DR
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45431-2772
Practice Address - Country:US
Practice Address - Phone:937-426-0106
Practice Address - Fax:937-426-7153
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34010401207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine