Provider Demographics
NPI:1457940736
Name:THACKER, JARRAD MICHAEL (CDCA173952)
Entity Type:Individual
Prefix:
First Name:JARRAD
Middle Name:MICHAEL
Last Name:THACKER
Suffix:
Gender:M
Credentials:CDCA173952
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1494 BEACON ST APT 3
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45230-2857
Mailing Address - Country:US
Mailing Address - Phone:513-314-0708
Mailing Address - Fax:
Practice Address - Street 1:4968 GLENWAY AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45238-3902
Practice Address - Country:US
Practice Address - Phone:513-853-6575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-12
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.173952101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)