Provider Demographics
NPI:1255942157
Name:JACKSON, DESTINY (HAS)
Entity type:Individual
Prefix:
First Name:DESTINY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:HAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3518 W 25TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44109-1995
Mailing Address - Country:US
Mailing Address - Phone:216-741-2241
Mailing Address - Fax:216-459-9821
Practice Address - Street 1:3518 W 25TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44109-1951
Practice Address - Country:US
Practice Address - Phone:216-741-2241
Practice Address - Fax:216-459-9821
Is Sole Proprietor?:No
Enumeration Date:2020-08-13
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH230031221041C0700X
171M00000X
OHIL.03403237700000X
OHS.2411200104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0325500Medicaid