Provider Demographics
NPI:1477127678
Name:JACKSON, CARLOS
Entity Type:Individual
Prefix:MR
First Name:CARLOS
Middle Name:
Last Name:JACKSON
Suffix:
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 1:3816 DUNLOE AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45213-2302
Mailing Address - Country:US
Mailing Address - Phone:513-834-0566
Mailing Address - Fax:
Practice Address - Street 1:4342 HARRISON AVE STE 1
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45211-3390
Practice Address - Country:US
Practice Address - Phone:513-574-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-13
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty