Healthcare Provider Details

I. General information

NPI: 1124440607
Provider Name (Legal Business Name): MS. JADE T FISHBURN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2014
Last Update Date: 12/09/2024
Certification Date: 12/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

624 MARKET AVE N
CANTON OH
44702-1017
US

IV. Provider business mailing address

624 MARKET AVE N
CANTON OH
44702-1017
US

V. Phone/Fax

Practice location:
  • Phone: 330-493-4553
  • Fax: 330-493-3761
Mailing address:
  • Phone: 330-493-4553
  • Fax: 330-493-3761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCDCII.161524
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberC2406388
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: