Provider Demographics
NPI:1679294987
Name:JACKSON, JALYSSA
Entity type:Individual
Prefix:
First Name:JALYSSA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:199 S CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43223-1301
Mailing Address - Country:US
Mailing Address - Phone:614-273-2273
Mailing Address - Fax:
Practice Address - Street 1:6313 SPRINGBORO PIKE APT 37
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45449-3421
Practice Address - Country:US
Practice Address - Phone:937-409-8489
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-06
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker