Provider Demographics
NPI:1174297055
Name:ZACKASEE, JENNIFER NICOLE (LSW, MSW, CDCA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:NICOLE
Last Name:ZACKASEE
Suffix:
Gender:F
Credentials:LSW, MSW, CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11369 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:NORTH LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:44452-9782
Mailing Address - Country:US
Mailing Address - Phone:330-965-9999
Mailing Address - Fax:330-757-0000
Practice Address - Street 1:11369 MARKET ST
Practice Address - Street 2:
Practice Address - City:NORTH LIMA
Practice Address - State:OH
Practice Address - Zip Code:44452-9782
Practice Address - Country:US
Practice Address - Phone:330-965-9999
Practice Address - Fax:330-757-0000
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-04
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.174489101YA0400X
OHS.21064201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPENDINGMedicaid