Provider Demographics
NPI:1669877460
Name:JACKSON, BEATRICE
Entity type:Individual
Prefix:
First Name:BEATRICE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14100 BARDWELL AVENUE
Mailing Address - Street 2:
Mailing Address - City:EAST CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44112
Mailing Address - Country:US
Mailing Address - Phone:216-212-1727
Mailing Address - Fax:
Practice Address - Street 1:14100 BARDWELL AVENUE
Practice Address - Street 2:
Practice Address - City:EAST CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44112
Practice Address - Country:US
Practice Address - Phone:216-212-1727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-23
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2998083343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2998083Medicaid