Provider Demographics
NPI:1841813060
Name:JACKSON, TADOSHYA J
Entity type:Individual
Prefix:
First Name:TADOSHYA
Middle Name:J
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 1:9430 VISTA CT
Mailing Address - Street 2:
Mailing Address - City:STREETSBORO
Mailing Address - State:OH
Mailing Address - Zip Code:44241-3600
Mailing Address - Country:US
Mailing Address - Phone:305-546-8203
Mailing Address - Fax:
Practice Address - Street 1:27600 CHAGRIN BLVD STE 300
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-4421
Practice Address - Country:US
Practice Address - Phone:216-387-6125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-21
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator