Individual
MR. KEVIN W JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
801 PRO DR STE D1, CELINA, OH 45822-3307
(419) 586-6489
(419) 586-8509
Mailing address
1140 S KNOXVILLE AVE STE D, SAINT MARYS, OH 45885-2609
(419) 300-1129
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
50.004297RX
OH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0121263
—
OH
Enumeration date
03/12/2015
Last updated
04/02/2024
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