Provider Demographics
NPI:1881645315
Name:LIU, JACKSON (MD)
Entity Type:Individual
Prefix:
First Name:JACKSON
Middle Name:
Last Name:LIU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:661 S TRIMBLE RD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44906-3437
Mailing Address - Country:US
Mailing Address - Phone:419-774-0478
Mailing Address - Fax:419-774-9887
Practice Address - Street 1:661 S TRIMBLE RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44906-3437
Practice Address - Country:US
Practice Address - Phone:419-774-0478
Practice Address - Fax:419-774-9887
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH87597207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology