Provider Demographics
NPI:1639945975
Name:DOUGLAS, JESSICA (RA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:RA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 STEUBENVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:OH
Mailing Address - Zip Code:43725-2401
Mailing Address - Country:US
Mailing Address - Phone:740-439-4532
Mailing Address - Fax:
Practice Address - Street 1:1009 STEUBENVILLE AVE
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:OH
Practice Address - Zip Code:43725-2401
Practice Address - Country:US
Practice Address - Phone:740-439-4532
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-28
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
OHRA.163860405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No405300000XOther Service ProvidersPrevention Professional