Provider Demographics
NPI:1831208768
Name:JACKSON, CARL E (MD)
Entity type:Individual
Prefix:DR
First Name:CARL
Middle Name:E
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:386 MEDWAY RD
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44143-3734
Mailing Address - Country:US
Mailing Address - Phone:440-953-1898
Mailing Address - Fax:440-460-0749
Practice Address - Street 1:386 MEDWAY RD
Practice Address - Street 2:
Practice Address - City:HIGHLAND HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44143-3734
Practice Address - Country:US
Practice Address - Phone:440-953-1898
Practice Address - Fax:440-460-0749
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35057489208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0881247Medicaid
OHF31556Medicare UPIN
OH0720061Medicare ID - Type UnspecifiedID#