Healthcare Provider Details

I. General information

NPI: 1639442130
Provider Name (Legal Business Name): JACQUILYN DRAKE LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2012
Last Update Date: 02/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8487 RIDGE RD
CINCINNATI OH
45236-1300
US

IV. Provider business mailing address

8487 RIDGE RD
CINCINNATI OH
45236-1300
US

V. Phone/Fax

Practice location:
  • Phone: 513-766-3350
  • Fax: 513-766-3358
Mailing address:
  • Phone: 513-766-3350
  • Fax: 513-766-3358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0005739
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: