Provider Demographics
NPI:1265495329
Name:JACKSON, BRADLEY S (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:S
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5386 COX SMITH RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-9289
Mailing Address - Country:US
Mailing Address - Phone:513-770-3466
Mailing Address - Fax:513-770-3467
Practice Address - Street 1:5386 COX SMITH RD
Practice Address - Street 2:SUITE A
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-9289
Practice Address - Country:US
Practice Address - Phone:513-770-3466
Practice Address - Fax:513-770-3467
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH060290208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH827681Medicaid