Provider Demographics
NPI:1720202500
Name:C WESLEY JACKSON JR PHD INC
Entity Type:Organization
Organization Name:C WESLEY JACKSON JR PHD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:C
Authorized Official - Middle Name:WESLEY
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:PHD
Authorized Official - Phone:216-321-9355
Mailing Address - Street 1:2980 WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44118-2450
Mailing Address - Country:US
Mailing Address - Phone:216-321-9355
Mailing Address - Fax:216-932-3341
Practice Address - Street 1:2980 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:CLEVELAND HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44118-2450
Practice Address - Country:US
Practice Address - Phone:216-321-9355
Practice Address - Fax:216-932-3341
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH474103TC0700X
MI000519103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0253309Medicaid
CP09651Medicare ID - Type Unspecified