Healthcare Provider Details

I. General information

NPI: 1720998305
Provider Name (Legal Business Name): JACKQULINE YVETTE JOHNSON-BOYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2026
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11521 GOVERNOR AVE
CLEVELAND OH
44111-3677
US

IV. Provider business mailing address

11521 GOVERNOR AVE
CLEVELAND OH
44111-3677
US

V. Phone/Fax

Practice location:
  • Phone: 216-251-8512
  • Fax:
Mailing address:
  • Phone: 216-251-8512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License NumberSZ935392
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: