Provider Demographics
NPI:1447600374
Name:JACKSON, LINDA
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 BROOKSEDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43081-2820
Mailing Address - Country:US
Mailing Address - Phone:614-882-9338
Mailing Address - Fax:614-882-3401
Practice Address - Street 1:7602 SLATE RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-8157
Practice Address - Country:US
Practice Address - Phone:614-626-2696
Practice Address - Fax:866-820-4098
Is Sole Proprietor?:No
Enumeration Date:2016-06-22
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC1700181101YP2500X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator