Provider Demographics
NPI:1801201314
Name:JACKIE EZELL
Entity Type:Organization
Organization Name:JACKIE EZELL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INDEPENDENT PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:DENESE
Authorized Official - Last Name:EZELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:33078-757-5431
Mailing Address - Street 1:516 GRIFFITH ST UNIT 401
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44510-2604
Mailing Address - Country:US
Mailing Address - Phone:330-787-5754
Mailing Address - Fax:
Practice Address - Street 1:516 GRIFFITH ST UNIT 401
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44510-2604
Practice Address - Country:US
Practice Address - Phone:330-787-5754
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-23
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2858760Medicaid