Provider Demographics
NPI:1396389441
Name:JACKSON, BRYANT DESHON
Entity Type:Individual
Prefix:
First Name:BRYANT
Middle Name:DESHON
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:563 E 260TH ST
Mailing Address - Street 2:
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44132-1948
Mailing Address - Country:US
Mailing Address - Phone:216-647-7477
Mailing Address - Fax:
Practice Address - Street 1:563 E 260TH ST
Practice Address - Street 2:
Practice Address - City:EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44132-1948
Practice Address - Country:US
Practice Address - Phone:216-647-7477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-01
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide