Healthcare Provider Details

I. General information

NPI: 1356505366
Provider Name (Legal Business Name): JACQUELINE A NUVAL PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2008
Last Update Date: 02/23/2023
Certification Date: 02/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 EASTON CMNS STE 125
COLUMBUS OH
43219-6223
US

IV. Provider business mailing address

PO BOX 10299
FORT WAYNE IN
46851-0299
US

V. Phone/Fax

Practice location:
  • Phone: 574-546-1900
  • Fax: 574-546-1999
Mailing address:
  • Phone: 574-546-1900
  • Fax: 574-546-1999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39000625A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number39024
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberP.08436
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20042692A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: