Provider Demographics
NPI:1265115828
Name:GRANATO, JACKSON RUSSEL
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:RUSSEL
Last Name:GRANATO
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 1:368 CRESCENT SPRING DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40206-2890
Mailing Address - Country:US
Mailing Address - Phone:913-653-2289
Mailing Address - Fax:
Practice Address - Street 1:368 CRESCENT SPRING DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40206-2890
Practice Address - Country:US
Practice Address - Phone:913-653-2289
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-10
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator