Provider Demographics
NPI:1124599014
Name:JACKSON, MORGAN (RN, CDCA)
Entity Type:Individual
Prefix:
First Name:MORGAN
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN, CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1616 GRANT ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-3663
Mailing Address - Country:US
Mailing Address - Phone:740-529-7356
Mailing Address - Fax:740-529-1351
Practice Address - Street 1:1616 GRANT ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-3663
Practice Address - Country:US
Practice Address - Phone:740-529-7356
Practice Address - Fax:740-529-1351
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.168866101YA0400X
OHRN.456286163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCDCA.168866OtherCHEMICAL DEPENDENCY PROFESSIONALS BOARD
OHRN.456286OtherOHIO NURSING