Provider Demographics
NPI:1942835467
Name:JACKSON, ULYSSES D III
Entity Type:Individual
Prefix:MR
First Name:ULYSSES
Middle Name:D
Last Name:JACKSON
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 WADSWORTH RD
Mailing Address - Street 2:
Mailing Address - City:WADSWORTH
Mailing Address - State:OH
Mailing Address - Zip Code:44281-9580
Mailing Address - Country:US
Mailing Address - Phone:330-564-5445
Mailing Address - Fax:
Practice Address - Street 1:205 WADSWORTH RD
Practice Address - Street 2:
Practice Address - City:WADSWORTH
Practice Address - State:OH
Practice Address - Zip Code:44281-9580
Practice Address - Country:US
Practice Address - Phone:234-217-8882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-04
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)