Provider Demographics
NPI:1982397063
Name:JACKSON, RAYSHOUN THOMAS
Entity Type:Individual
Prefix:
First Name:RAYSHOUN
Middle Name:THOMAS
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 1:3366 W 130TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44111-2614
Mailing Address - Country:US
Mailing Address - Phone:216-703-2397
Mailing Address - Fax:
Practice Address - Street 1:3366 W 130TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44111-2614
Practice Address - Country:US
Practice Address - Phone:216-703-2397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-02
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)