Provider Demographics
NPI:1235428780
Name:JACKSON, JOY A (LISW-S)
Entity Type:Individual
Prefix:
First Name:JOY
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:JOY
Other - Middle Name:A
Other - Last Name:LANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LISW-S
Mailing Address - Street 1:12200 FAIRHILL RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44120-1058
Mailing Address - Country:US
Mailing Address - Phone:216-923-0333
Mailing Address - Fax:216-923-0343
Practice Address - Street 1:11801 BUCKEYE RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44120-2620
Practice Address - Country:US
Practice Address - Phone:216-831-2255
Practice Address - Fax:216-378-3906
Is Sole Proprietor?:No
Enumeration Date:2011-04-06
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.09011071041C0700X
NCC0145681041C0700X
TX1068161041C0700X
OHI.11010491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0268768Medicaid
OH02686768Medicaid