Provider Demographics
NPI:1275944712
Name:FIELDS, JACQUELIN ANN (LICDC LSW)
Entity Type:Individual
Prefix:
First Name:JACQUELIN
Middle Name:ANN
Last Name:FIELDS
Suffix:
Gender:F
Credentials:LICDC LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27030 CEDAR RD
Mailing Address - Street 2:APT.507, BUILDING 2
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44122-1195
Mailing Address - Country:US
Mailing Address - Phone:216-342-4222
Mailing Address - Fax:216-231-5040
Practice Address - Street 1:1905 E 89TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-2007
Practice Address - Country:US
Practice Address - Phone:216-231-3772
Practice Address - Fax:216-231-5040
Is Sole Proprietor?:No
Enumeration Date:2014-05-19
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH852174101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)