Provider Demographics
NPI:1639442130
Name:DRAKE, JACQUILYN (LISW)
Entity Type:Individual
Prefix:MS
First Name:JACQUILYN
Middle Name:
Last Name:DRAKE
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 1:8487 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45236-1300
Mailing Address - Country:US
Mailing Address - Phone:513-766-3350
Mailing Address - Fax:513-766-3358
Practice Address - Street 1:8487 RIDGE RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45236-1300
Practice Address - Country:US
Practice Address - Phone:513-766-3350
Practice Address - Fax:513-766-3358
Is Sole Proprietor?:No
Enumeration Date:2012-02-14
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH00057391041C0700X
101YM0800X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator