Individual
MIKE JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
6700 AYLESHIRE DR, SOLON, OH 44139-3866
(440) 759-2512
Mailing address
6700 AYLESHIRE DR, SOLON, OH 44139-3866
(440) 759-2512
Taxonomy
Speciality
Code
Description
License number
State
172A00000X
Driver
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
910001002810
—
OH
Enumeration date
12/08/2020
Last updated
12/08/2020
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