Provider Demographics
NPI:1821720889
Name:JACKSON, RONALD L SR (EDD)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:L
Last Name:JACKSON
Suffix:SR
Gender:M
Credentials:EDD
Other - Prefix:DR
Other - First Name:RONALD
Other - Middle Name:L
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:3371 ANACONDA DR STE 258
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45211-3701
Mailing Address - Country:US
Mailing Address - Phone:513-604-2551
Mailing Address - Fax:
Practice Address - Street 1:3371 ANACONDA DR STE 258
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45211-3701
Practice Address - Country:US
Practice Address - Phone:513-604-2551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-28
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH1290675171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor