Individual
MR. CHARLES D JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
4856 W.12TH, SUITE 1, CLEVELAND, OH 44109-3424
(440) 749-3019
Mailing address
4856 W 12TH ST, CLEVELAND, OH 44109-5611
(440) 749-3019
Taxonomy
Speciality
Code
Description
License number
State
172A00000X
Driver
Primary
RS884250
OH
Other
Enumeration date
05/09/2013
Last updated
11/22/2013
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