Provider Demographics
NPI:1871254631
Name:JACKSON, MARRY EMMA (QMHS ASSOC)
Entity Type:Individual
Prefix:
First Name:MARRY
Middle Name:EMMA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:QMHS ASSOC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 W MONUMENT AVE FL 7
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45402-1274
Mailing Address - Country:US
Mailing Address - Phone:937-461-4300
Mailing Address - Fax:
Practice Address - Street 1:5290 COBBLEGATE DRIVE
Practice Address - Street 2:7TH FLOOR
Practice Address - City:MORAINE
Practice Address - State:OH
Practice Address - Zip Code:45439-4540
Practice Address - Country:US
Practice Address - Phone:937-293-2510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-04
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0301947Medicaid