Provider Demographics
NPI:1780329896
Name:JACKSON, KYLE RAYMOND
Entity type:Individual
Prefix:MR
First Name:KYLE
Middle Name:RAYMOND
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 1:3640 COLONEL GLENN HWY
Mailing Address - Street 2:117 HEALTH SCIENCES BUILDING
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45435-0001
Mailing Address - Country:US
Mailing Address - Phone:937-775-3458
Mailing Address - Fax:
Practice Address - Street 1:3640 COLONEL GLENN HWY
Practice Address - Street 2:117 HEALTH SCIENCES BUILDING
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45435-0001
Practice Address - Country:US
Practice Address - Phone:937-775-3458
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-03
Last Update Date:2024-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OH390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No171M00000XOther Service ProvidersCase Manager/Care Coordinator