Provider Demographics
NPI:1912928441
Name:JACKSON, LARRY D (PA-C)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:D
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16620 DOWNEY GLEN TRL
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:OH
Mailing Address - Zip Code:44021-9319
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 GYPSY LN
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44504-1315
Practice Address - Country:US
Practice Address - Phone:330-884-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50-000351363A00000X
OH50000351146D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH970029949OtherMEDICARE TRAVELERS RR-GA
OHS62128Medicare UPIN
OHJAPA16719Medicare ID - Type Unspecified