Provider Demographics
NPI:1578824447
Name:JACKSON, CHANTILLE UNIQUE (MSW, LSW)
Entity Type:Individual
Prefix:
First Name:CHANTILLE
Middle Name:UNIQUE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MSW, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 E BAGLEY RD
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:OH
Mailing Address - Zip Code:44017-2058
Mailing Address - Country:US
Mailing Address - Phone:440-260-8300
Mailing Address - Fax:
Practice Address - Street 1:202 E BAGLEY RD
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:OH
Practice Address - Zip Code:44017-2058
Practice Address - Country:US
Practice Address - Phone:440-260-8300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-06
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1101606251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health