Provider Demographics
NPI:1801224571
Name:DR. JACKIE BERKOWITZ
Entity Type:Organization
Organization Name:DR. JACKIE BERKOWITZ
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BERKOWITZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:614-475-9800
Mailing Address - Street 1:955 N HAMILTON RD
Mailing Address - Street 2:
Mailing Address - City:GAHANNA
Mailing Address - State:OH
Mailing Address - Zip Code:43230-1758
Mailing Address - Country:US
Mailing Address - Phone:614-475-9800
Mailing Address - Fax:614-475-4222
Practice Address - Street 1:955 N HAMILTON RD
Practice Address - Street 2:
Practice Address - City:GAHANNA
Practice Address - State:OH
Practice Address - Zip Code:43230-1758
Practice Address - Country:US
Practice Address - Phone:614-475-9800
Practice Address - Fax:614-475-4222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-16
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300142681223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH122384615051OtherCARESOURCE