Provider Demographics
NPI:1497255343
Name:LOCKETT, JACQUELINE NASHELLE (LISW)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:NASHELLE
Last Name:LOCKETT
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35104 EUCLID AVE STE 306
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094-4566
Mailing Address - Country:US
Mailing Address - Phone:440-571-5009
Mailing Address - Fax:440-571-4850
Practice Address - Street 1:35104 EUCLID AVE STE 306
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-4566
Practice Address - Country:US
Practice Address - Phone:216-387-1759
Practice Address - Fax:440-571-5009
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-16
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.13026021041C0700X
OHI.2102892261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0268275Medicaid