Provider Demographics
NPI:1326734682
Name:COLEMAN, JACQUELYN C (EDS)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELYN
Middle Name:C
Last Name:COLEMAN
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16609 DRAKE RD
Mailing Address - Street 2:
Mailing Address - City:STRONGSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44136-7311
Mailing Address - Country:US
Mailing Address - Phone:330-416-6881
Mailing Address - Fax:
Practice Address - Street 1:16609 DRAKE RD
Practice Address - Street 2:
Practice Address - City:STRONGSVILLE
Practice Address - State:OH
Practice Address - Zip Code:44136-7311
Practice Address - Country:US
Practice Address - Phone:330-416-6881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-11
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH3164743103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool