Basic Information
| Provider Information | |||||||||
| NPI: | 1962081455 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | ALAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 231 ALBERT SABIN WAY, MSB 1654, ML 0769 | ||||||||
| Address2: | UC EMERGENCY MEDICINE | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452670769 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135585281 | ||||||||
| FaxNumber: | 5135585791 | ||||||||
| Practice Location | |||||||||
| Address1: | 234 GOODMAN STREET | ||||||||
| Address2: | CENTER FOR EMERGENCY CARE | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452190796 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135585281 | ||||||||
| FaxNumber: | 5135585791 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2021 | ||||||||
| LastUpdateDate: | 04/03/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.