Provider Demographics
NPI:1275028714
Name:JACKSON, DWAYNE JULIUS (CPST)
Entity Type:Individual
Prefix:
First Name:DWAYNE
Middle Name:JULIUS
Last Name:JACKSON
Suffix:
Gender:M
Credentials:CPST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1293 COPLEY RD
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44320-2766
Mailing Address - Country:US
Mailing Address - Phone:330-374-1199
Mailing Address - Fax:
Practice Address - Street 1:1293 COPLEY RD
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44320-2766
Practice Address - Country:US
Practice Address - Phone:330-374-1199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-27
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer