Healthcare Provider Details

I. General information

NPI: 1952708448
Provider Name (Legal Business Name): JACQUELINE CARSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2014
Last Update Date: 11/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3471 E 78TH ST
CLEVELAND OH
44127-2018
US

IV. Provider business mailing address

3471 EAST 78TH STREET
CLEVELAND OH
44127
US

V. Phone/Fax

Practice location:
  • Phone: 216-570-7869
  • Fax:
Mailing address:
  • Phone: 216-570-7869
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number401053050310
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number401053050310
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: