Provider Demographics
NPI:1740593060
Name:WOOD, JESSICA ROSE (PC)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:ROSE
Last Name:WOOD
Suffix:
Gender:F
Credentials:PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14242 RAVENNA RD
Mailing Address - Street 2:
Mailing Address - City:NEWBURY
Mailing Address - State:OH
Mailing Address - Zip Code:44065-9621
Mailing Address - Country:US
Mailing Address - Phone:216-571-2133
Mailing Address - Fax:
Practice Address - Street 1:12557 RAVENWOOD DR
Practice Address - Street 2:
Practice Address - City:CHARDON
Practice Address - State:OH
Practice Address - Zip Code:44024-9009
Practice Address - Country:US
Practice Address - Phone:440-285-3568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-15
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC 0900002101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health