Basic Information
| Provider Information | |||||||||
| NPI: | 1285278325 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | VERNESSA | ||||||||
| MiddleName: | FAYE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | CT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 23220 CHAGRIN BLVD APT 284 | ||||||||
| Address2: | |||||||||
| City: | BEACHWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441225440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4407153337 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 22101 FAIRMOUNT BLVD | ||||||||
| Address2: | |||||||||
| City: | SHAKER HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2169322800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2019 | ||||||||
| LastUpdateDate: | 11/01/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | C.1902019-TRNE | OH | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.