Provider Demographics
NPI:1235280645
Name:JACKSON, DONNA R (DONNA JACKSON, PHD)
Entity Type:Individual
Prefix:DR
First Name:DONNA
Middle Name:R
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DONNA JACKSON, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2724 MADISON RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45209-2209
Mailing Address - Country:US
Mailing Address - Phone:513-631-9922
Mailing Address - Fax:
Practice Address - Street 1:2724 MADISON RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45209-2209
Practice Address - Country:US
Practice Address - Phone:513-631-9922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-13
Last Update Date:2016-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2146103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCP05961Medicare ID - Type Unspecified