Provider Demographics
NPI:1659473791
Name:JACKSON, DAVID LANCE (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:LANCE
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3529 FORTUNA DR
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44312-5282
Mailing Address - Country:US
Mailing Address - Phone:330-644-0022
Mailing Address - Fax:330-644-0328
Practice Address - Street 1:3529 FORTUNA DR
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44312-5282
Practice Address - Country:US
Practice Address - Phone:330-644-0022
Practice Address - Fax:330-644-0328
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH-35055410207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0686066Medicaid
OHJA0632494Medicare ID - Type Unspecified
OHA14839Medicare UPIN