Provider Demographics
NPI:1437224813
Name:JACKSON, CHARLES WESLEY JR (PH D)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:WESLEY
Last Name:JACKSON
Suffix:JR
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:C
Other - Middle Name:WESLEY
Other - Last Name:JACKSON
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:PH D
Mailing Address - Street 1:2980 WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44118-2450
Mailing Address - Country:US
Mailing Address - Phone:216-321-9355
Mailing Address - Fax:216-932-3341
Practice Address - Street 1:2980 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:CLEVELAND HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44118-2450
Practice Address - Country:US
Practice Address - Phone:216-321-9355
Practice Address - Fax:216-932-3341
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPSYCHOLOGIST 474103TC0700X
MIPSYCHOLOGIST 000519103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0253309Medicaid
OH0253309Medicaid
OHCP34291Medicare PIN