Provider Demographics
NPI:1699858746
Name:ROBERTS, JACQUELINE ROSE (LSW)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:ROSE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1402 PLYMOUTH RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44109-3546
Mailing Address - Country:US
Mailing Address - Phone:216-916-0522
Mailing Address - Fax:
Practice Address - Street 1:3076A REMSEN RD
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-9225
Practice Address - Country:US
Practice Address - Phone:330-722-0750
Practice Address - Fax:330-723-0068
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS31826104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker