Basic Information
| Provider Information | |||||||||
| NPI: | 1467809574 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | DAWSON | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 340 S BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443081529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3302533100 | ||||||||
| FaxNumber: | 3303768002 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 PENFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443102912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307626110 | ||||||||
| FaxNumber: | 3302536810 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2016 | ||||||||
| LastUpdateDate: | 05/18/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | S.0005654 | OH | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.