Provider Demographics
NPI:1518777457
Name:JACKSON, TAVON DESHANE
Entity type:Individual
Prefix:
First Name:TAVON
Middle Name:DESHANE
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 1:800 6TH ST NW APT 2
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44703-2538
Mailing Address - Country:US
Mailing Address - Phone:330-414-9162
Mailing Address - Fax:
Practice Address - Street 1:800 6TH ST NW APT 2
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44703-2538
Practice Address - Country:US
Practice Address - Phone:330-414-9162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-13
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome HealthGroup - Single Specialty