Healthcare Provider Details

I. General information

NPI: 1477938223
Provider Name (Legal Business Name): JACQUELINE VERNADE WILLIS LCDC II
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2015
Last Update Date: 04/03/2024
Certification Date: 04/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 E MARKET ST
AKRON OH
44305-2421
US

IV. Provider business mailing address

615 ELSINORE PL STE 200
CINCINNATI OH
45202-1457
US

V. Phone/Fax

Practice location:
  • Phone: 330-434-4141
  • Fax:
Mailing address:
  • Phone: 833-510-4357
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number162419
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number162419
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: