Provider Demographics
NPI:1053936773
Name:JACKSON, DEJOUR J
Entity type:Individual
Prefix:
First Name:DEJOUR
Middle Name:J
Last Name:JACKSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4697 HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:BELLAIRE
Mailing Address - State:OH
Mailing Address - Zip Code:43906-1338
Mailing Address - Country:US
Mailing Address - Phone:740-968-7006
Mailing Address - Fax:
Practice Address - Street 1:4697 HARRISON ST
Practice Address - Street 2:
Practice Address - City:BELLAIRE
Practice Address - State:OH
Practice Address - Zip Code:43906-1338
Practice Address - Country:US
Practice Address - Phone:740-968-7006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-09
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator