Provider Demographics
NPI:1477569507
Name:BERKOWITZ, JACKIE (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:JACKIE
Middle Name:
Last Name:BERKOWITZ
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:164 E GAY ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-3207
Mailing Address - Country:US
Mailing Address - Phone:614-253-6364
Mailing Address - Fax:
Practice Address - Street 1:955 N HAMILTON RD
Practice Address - Street 2:
Practice Address - City:GAHANNA
Practice Address - State:OH
Practice Address - Zip Code:43230-1758
Practice Address - Country:US
Practice Address - Phone:614-475-9800
Practice Address - Fax:614-475-4222
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH142681223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH$$$$$$$$$051OtherCARESOURCE