Provider Demographics
NPI:1710336896
Name:JACKSON YOUNG, SHAWNA (LCDC III, LISW)
Entity Type:Individual
Prefix:
First Name:SHAWNA
Middle Name:
Last Name:JACKSON YOUNG
Suffix:
Gender:F
Credentials:LCDC III, LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13605 CAINE AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44105-6335
Mailing Address - Country:US
Mailing Address - Phone:216-990-8773
Mailing Address - Fax:
Practice Address - Street 1:24100 CHAGRIN BLVD STE 330
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122
Practice Address - Country:US
Practice Address - Phone:216-990-8773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-08
Last Update Date:2018-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLCDCIII.161563101YA0400X
OHS.1600353104100000X
OHI.18010431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker