Provider Demographics
NPI:1255183398
Name:JACKSON, CLIFTON
Entity type:Individual
Prefix:
First Name:CLIFTON
Middle Name:
Last Name:JACKSON
Suffix:
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 1:4248 GELBRAY CT
Mailing Address - Street 2:
Mailing Address - City:OBETZ
Mailing Address - State:OH
Mailing Address - Zip Code:43207-3771
Mailing Address - Country:US
Mailing Address - Phone:614-516-1903
Mailing Address - Fax:
Practice Address - Street 1:415 E BROAD ST STE 113
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-3800
Practice Address - Country:US
Practice Address - Phone:614-516-1903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-02
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator