Healthcare Provider Details

I. General information

NPI: 1740721729
Provider Name (Legal Business Name): JILLIAN NANCY-GRACE BUENO LISW-S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2017
Last Update Date: 05/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1730 W 25TH ST
CLEVELAND OH
44113
US

IV. Provider business mailing address

20000 LORAIN RD APT 607
FAIRVIEW PARK OH
44126-3479
US

V. Phone/Fax

Practice location:
  • Phone: 216-696-4030
  • Fax:
Mailing address:
  • Phone: 216-402-3060
  • Fax: 216-861-7671

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.1700211-SUPV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: