Individual
EARLY LEE JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
22639 EUCLID AVE, EUCLID, OH 44117-1622
(216) 404-1900
Mailing address
6137 EDWARD ST APT 202, NORFOLK, VA 23513-1575
(610) 226-7670
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
175805
OH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
175805
—
OH
Enumeration date
06/21/2021
Last updated
06/21/2021
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