Provider Demographics
NPI:1467996017
Name:JACKSON, CHARLA L
Entity Type:Individual
Prefix:
First Name:CHARLA
Middle Name:L
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 1:4300 LYNN RD STE 201
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-7838
Mailing Address - Country:US
Mailing Address - Phone:216-264-0008
Mailing Address - Fax:234-260-4799
Practice Address - Street 1:4300 LYNN RD STE 201
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-7838
Practice Address - Country:US
Practice Address - Phone:216-264-0008
Practice Address - Fax:234-260-4799
Is Sole Proprietor?:No
Enumeration Date:2016-12-15
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA164081101YA0400X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0267301Medicaid