Provider Demographics
NPI:1699881581
Name:JACKSON FAMILY PRACTICE, INC.
Entity type:Organization
Organization Name:JACKSON FAMILY PRACTICE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:R
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-966-1319
Mailing Address - Street 1:7072 MEARS GATE DR. NW
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-8850
Mailing Address - Country:US
Mailing Address - Phone:330-966-1319
Mailing Address - Fax:330-966-1321
Practice Address - Street 1:7072 MEARS GATE DR. NW
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-8850
Practice Address - Country:US
Practice Address - Phone:330-966-1319
Practice Address - Fax:330-966-1321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35055884207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0684344Medicaid
OH2206713Medicaid
OH0684344Medicaid
OH9310151Medicare PIN
OHH24014Medicare UPIN