Provider Demographics
NPI:1255143061
Name:JACKSON, PHILLIP A SR
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:A
Last Name:JACKSON
Suffix:SR
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 1:237 HILLSIDE CIR APT 1
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44907-1763
Mailing Address - Country:US
Mailing Address - Phone:614-886-8392
Mailing Address - Fax:
Practice Address - Street 1:237 HILLSIDE CIR APT 1
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44907-1763
Practice Address - Country:US
Practice Address - Phone:614-886-8392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-21
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174H00000XOther Service ProvidersHealth EducatorGroup - Multi-Specialty