Provider Demographics
NPI:1154048213
Name:JACKSON, RAYMOND (QMHS)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:QMHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4521 GRANADA BLVD
Mailing Address - Street 2:
Mailing Address - City:WARRENSVILLE HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44128
Mailing Address - Country:US
Mailing Address - Phone:216-527-3301
Mailing Address - Fax:
Practice Address - Street 1:1865 N RIDGE RD E STE A
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44055-3359
Practice Address - Country:US
Practice Address - Phone:440-324-1300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-20
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator