Provider Demographics
NPI:1710517404
Name:JACKSON, ALYX (CDCA)
Entity Type:Individual
Prefix:
First Name:ALYX
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 GERVAIS RD
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN FURNACE
Mailing Address - State:OH
Mailing Address - Zip Code:45629-8742
Mailing Address - Country:US
Mailing Address - Phone:740-259-7000
Mailing Address - Fax:740-259-7003
Practice Address - Street 1:303 GERVAIS RD
Practice Address - Street 2:
Practice Address - City:FRANKLIN FURNACE
Practice Address - State:OH
Practice Address - Zip Code:45629-8742
Practice Address - Country:US
Practice Address - Phone:740-259-7000
Practice Address - Fax:740-259-7003
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-22
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.172454171M00000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty