Basic Information
| Provider Information | |||||||||
| NPI: | 1932640265 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | BETHANY | ||||||||
| MiddleName: | ROSE | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5450 FRANTZ RD STE 360 | ||||||||
| Address2: | |||||||||
| City: | DUBLIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430164141 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4343 ALL SEASONS DR STE 160 | ||||||||
| Address2: | |||||||||
| City: | HILLIARD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430261962 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6145412676 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2017 | ||||||||
| LastUpdateDate: | 12/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 10939759-1204 | UT | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 34.014571 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.