Provider Demographics
NPI:1467134544
Name:JACKSON, TERRANCE LAMONT SR
Entity Type:Individual
Prefix:
First Name:TERRANCE
Middle Name:LAMONT
Last Name:JACKSON
Suffix:SR
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 1:2155 GEORGETOWN RD NE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44704-2257
Mailing Address - Country:US
Mailing Address - Phone:816-377-7225
Mailing Address - Fax:
Practice Address - Street 1:2155 GEORGETOWN RD NE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44704-2257
Practice Address - Country:US
Practice Address - Phone:816-377-7225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
No101Y00000XBehavioral Health & Social Service ProvidersCounselor