Healthcare Provider Details

I. General information

NPI: 1104780097
Provider Name (Legal Business Name): VICKIE JONES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23611 CHAGRIN BLVD
BEACHWOOD OH
44122-5540
US

IV. Provider business mailing address

19242 SCOTTSDALE BLVD
SHAKER HEIGHTS OH
44122-6418
US

V. Phone/Fax

Practice location:
  • Phone: 866-534-2639
  • Fax: 800-480-7578
Mailing address:
  • Phone: 216-233-2258
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: