Provider Demographics
NPI:1730185844
Name:JACKO, JOSEPH G (MD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:G
Last Name:JACKO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4885 OLENTANGY RIVER RD
Mailing Address - Street 2:SUITE 2-50
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43214-1952
Mailing Address - Country:US
Mailing Address - Phone:614-451-1551
Mailing Address - Fax:614-451-2326
Practice Address - Street 1:4885 OLENTANGY RIVER RD
Practice Address - Street 2:SUITE 2-50
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-1952
Practice Address - Country:US
Practice Address - Phone:614-451-1551
Practice Address - Fax:614-451-2326
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-23
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.055488207R00000X, 207RS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0070272Medicaid
OHH119560Medicare PIN