Provider Demographics
NPI:1538675632
Name:JACKSON, DENISE DIANE
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:DIANE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4298 ROCKY RIVER DR
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44135-1951
Mailing Address - Country:US
Mailing Address - Phone:216-526-4729
Mailing Address - Fax:216-781-2252
Practice Address - Street 1:4298 ROCKY RIVER DR
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44135-1951
Practice Address - Country:US
Practice Address - Phone:216-526-4729
Practice Address - Fax:216-781-2252
Is Sole Proprietor?:No
Enumeration Date:2017-12-27
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH164132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)