Provider Demographics
NPI:1417073552
Name:JACKSON, CHARLENE J (PT)
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:J
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 W 27TH ST
Mailing Address - Street 2:
Mailing Address - City:ASHTABULA
Mailing Address - State:OH
Mailing Address - Zip Code:44004-4975
Mailing Address - Country:US
Mailing Address - Phone:440-997-5427
Mailing Address - Fax:440-997-5486
Practice Address - Street 1:416 W 27TH ST
Practice Address - Street 2:
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-4975
Practice Address - Country:US
Practice Address - Phone:440-997-5427
Practice Address - Fax:440-997-5486
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT01263225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0747777Medicaid
OH366576Medicare ID - Type UnspecifiedLAYTON PHYS. THERAPY