Provider Demographics
NPI:1740827740
Name:PAVAL, JACKIE B
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:B
Last Name:PAVAL
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 1:6264 BIG CREEK PKWY APT 6C
Mailing Address - Street 2:
Mailing Address - City:PARMA HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44130-2207
Mailing Address - Country:US
Mailing Address - Phone:216-548-9406
Mailing Address - Fax:
Practice Address - Street 1:9701 BROOKPARK RD # 241C
Practice Address - Street 2:
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44129-6824
Practice Address - Country:US
Practice Address - Phone:216-548-9406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-09
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1902365101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health