Provider Demographics
NPI:1396755187
Name:WRIGHT, JACKSON T JR (MD PHD)
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:T
Last Name:WRIGHT
Suffix:JR
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3605 WARRENSVILLE CENTER RD
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:SHAKER HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44122
Mailing Address - Country:US
Mailing Address - Phone:216-286-6295
Mailing Address - Fax:216-286-6341
Practice Address - Street 1:11100 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106
Practice Address - Country:US
Practice Address - Phone:216-844-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-060828207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH364150OtherWELLCARE
OH0643909OtherAETNA
OH000000224345OtherUNISON
OH0832460Medicaid
OH746010OtherBUCKEYE
OH000000539619OtherANTHEM
OHP00751953Medicare PIN
OH000000224345OtherUNISON
OH0643909OtherAETNA
OH746010OtherBUCKEYE