Provider Demographics
NPI:1467047613
Name:JACKSON, VANESSA MICHELINE
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:MICHELINE
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 1:620 W 57TH ST
Mailing Address - Street 2:
Mailing Address - City:ASHTABULA
Mailing Address - State:OH
Mailing Address - Zip Code:44004-7114
Mailing Address - Country:US
Mailing Address - Phone:440-813-8476
Mailing Address - Fax:
Practice Address - Street 1:2801 C CT
Practice Address - Street 2:
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-4577
Practice Address - Country:US
Practice Address - Phone:440-998-0722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-09
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)