Provider Demographics
NPI:1346566031
Name:JACKSON, MOLLY J (MSN, CRNP)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:J
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MSN, CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10900 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44106-1712
Mailing Address - Country:US
Mailing Address - Phone:216-368-1076
Mailing Address - Fax:
Practice Address - Street 1:323 WHITETAIL DR
Practice Address - Street 2:
Practice Address - City:CHAGRIN FALLS
Practice Address - State:OH
Practice Address - Zip Code:44022-4181
Practice Address - Country:US
Practice Address - Phone:440-338-3949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-20
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN23078363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health