Provider Demographics
NPI:1356903942
Name:LAVERICK-MILLER, JACQUELYNN NICOLE
Entity type:Individual
Prefix:MRS
First Name:JACQUELYNN
Middle Name:NICOLE
Last Name:LAVERICK-MILLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5982 RHODES RD
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:OH
Mailing Address - Zip Code:44240-8100
Mailing Address - Country:US
Mailing Address - Phone:330-673-1347
Mailing Address - Fax:330-678-3677
Practice Address - Street 1:45875 BELL SCHOOL RD STE B
Practice Address - Street 2:
Practice Address - City:EAST LIVERPOOL
Practice Address - State:OH
Practice Address - Zip Code:43920-8728
Practice Address - Country:US
Practice Address - Phone:330-397-6007
Practice Address - Fax:234-254-5655
Is Sole Proprietor?:No
Enumeration Date:2019-07-03
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OHS.2403887-TRNE104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator