Provider Demographics
NPI:1932622867
Name:JACKSON, RUSSELL EMANUEL (AT)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:EMANUEL
Last Name:JACKSON
Suffix:
Gender:M
Credentials:AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 SHERIDAN FOREST RD
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534-7103
Mailing Address - Country:US
Mailing Address - Phone:419-215-8888
Mailing Address - Fax:
Practice Address - Street 1:406 SHERIDAN FOREST RD
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-7103
Practice Address - Country:US
Practice Address - Phone:419-215-8888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-23
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT00052402255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer