Healthcare Provider Details

I. General information

NPI: 1457940736
Provider Name (Legal Business Name): JARRAD MICHAEL THACKER CDCA.173952
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2021
Last Update Date: 01/12/2021
Certification Date: 01/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4968 GLENWAY AVE
CINCINNATI OH
45238-3902
US

IV. Provider business mailing address

1494 BEACON ST APT 3
CINCINNATI OH
45230-2857
US

V. Phone/Fax

Practice location:
  • Phone: 513-853-6575
  • Fax:
Mailing address:
  • Phone: 513-314-0708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.173952
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: