Basic Information
| Provider Information | |||||||||
| NPI: | 1154048213 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | RAYMOND | ||||||||
| MiddleName: | |||||||||
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| Credential: | QMHS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4521 GRANADA BLVD | ||||||||
| Address2: | |||||||||
| City: | WARRENSVILLE HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2165273301 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1865 N RIDGE RD E STE A | ||||||||
| Address2: | |||||||||
| City: | LORAIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440553359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403241300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2022 | ||||||||
| LastUpdateDate: | 10/20/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.