Provider Demographics
NPI:1003318551
Name:JACKMAN, DANIEL S (CDCA)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:S
Last Name:JACKMAN
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 PARK AVE W
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44906-3706
Mailing Address - Country:US
Mailing Address - Phone:419-528-5993
Mailing Address - Fax:567-560-5486
Practice Address - Street 1:597 PARK AVE E
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44905-2848
Practice Address - Country:US
Practice Address - Phone:419-774-3538
Practice Address - Fax:419-774-3544
Is Sole Proprietor?:No
Enumeration Date:2018-03-01
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OHCDCA.169811101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator