Provider Demographics
NPI:1477925287
Name:JACKSON, KEVIN (CAA)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:CAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 NORTHBORO DR
Mailing Address - Street 2:
Mailing Address - City:MAYFIELD VILLAGE
Mailing Address - State:OH
Mailing Address - Zip Code:44143-3429
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6780 MAYFIELD RD
Practice Address - Street 2:
Practice Address - City:MAYFIELD HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44124-2203
Practice Address - Country:US
Practice Address - Phone:440-312-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-21
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH67.000265367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant