Healthcare Provider Details

I. General information

NPI: 1255942157
Provider Name (Legal Business Name): DESTINY JACKSON HAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2020
Last Update Date: 08/26/2024
Certification Date: 08/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3518 W 25TH ST
CLEVELAND OH
44109-1951
US

IV. Provider business mailing address

3518 W 25TH ST
CLEVELAND OH
44109-1995
US

V. Phone/Fax

Practice location:
  • Phone: 216-741-2241
  • Fax: 216-459-9821
Mailing address:
  • Phone: 216-741-2241
  • Fax: 216-459-9821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.2411200
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number23003122
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberIL.03403
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: