Provider Demographics
NPI:1487740114
Name:COCKLEY, JACKSON (DDS)
Entity type:Individual
Prefix:DR
First Name:JACKSON
Middle Name:
Last Name:COCKLEY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1145 ASPIRA CT
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44906-4125
Mailing Address - Country:US
Mailing Address - Phone:419-774-7529
Mailing Address - Fax:419-774-7529
Practice Address - Street 1:1145 ASPIRA CT
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44906-4125
Practice Address - Country:US
Practice Address - Phone:419-774-7529
Practice Address - Fax:419-774-7529
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300219451223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2704818Medicaid