1861915852 NPI number — ALVIN GLEN JACKSON LPC

Table of content: ALVIN GLEN JACKSON LPC (NPI 1861915852)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861915852 NPI number — ALVIN GLEN JACKSON LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
ALVIN
Provider Middle Name:
GLEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1861915852
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/19/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 78000 DEPT 7816125
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DETROIT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48278-1625
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
614-355-8004
Provider Business Mailing Address Fax Number:
614-722-4565

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
495 EAST MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43215
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
614-355-8055
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/21/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  C.1700707 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1473276 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".