Provider Demographics
NPI:1093561169
Name:JACKSON, ALLEN CHRISTOPHER DAVID
Entity type:Individual
Prefix:
First Name:ALLEN
Middle Name:CHRISTOPHER DAVID
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1710 N COVE BLVD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-4020
Mailing Address - Country:US
Mailing Address - Phone:419-380-7525
Mailing Address - Fax:855-513-3001
Practice Address - Street 1:1710 N COVE BLVD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-4020
Practice Address - Country:US
Practice Address - Phone:419-380-7525
Practice Address - Fax:855-513-3001
Is Sole Proprietor?:No
Enumeration Date:2024-04-29
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator