Provider Demographics
NPI:1063278489
Name:JACKSON, BRANDY ANTOINETTE
Entity type:Individual
Prefix:
First Name:BRANDY
Middle Name:ANTOINETTE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BRANDY
Other - Middle Name:ANTOINETTE
Other - Last Name:GAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9250 MILES PARK AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44105-5166
Mailing Address - Country:US
Mailing Address - Phone:216-417-0216
Mailing Address - Fax:
Practice Address - Street 1:9250 MILES PARK AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44105-5166
Practice Address - Country:US
Practice Address - Phone:216-417-0216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-23
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator