Provider Demographics
NPI:1558145672
Name:JACKSON, SABE ANTHONY
Entity Type:Individual
Prefix:
First Name:SABE
Middle Name:ANTHONY
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 1:48 RANDOLPH ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:45177-2731
Mailing Address - Country:US
Mailing Address - Phone:937-481-5645
Mailing Address - Fax:
Practice Address - Street 1:48 RANDOLPH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:OH
Practice Address - Zip Code:45177-2731
Practice Address - Country:US
Practice Address - Phone:937-481-5645
Practice Address - Fax:937-481-5647
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health