Provider Demographics
NPI:1154555175
Name:THE LORENZO G JACKSON FOUNDATION
Entity type:Organization
Organization Name:THE LORENZO G JACKSON FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:MS
Authorized Official - Phone:216-799-8292
Mailing Address - Street 1:4756 E 174TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44128-3924
Mailing Address - Country:US
Mailing Address - Phone:216-799-8292
Mailing Address - Fax:
Practice Address - Street 1:4756 E 174TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44128-3924
Practice Address - Country:US
Practice Address - Phone:216-799-8292
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-05
Last Update Date:2009-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization