Healthcare Provider Details

I. General information

NPI: 1437859246
Provider Name (Legal Business Name): JACKIE FRASER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2023
Last Update Date: 07/19/2024
Certification Date: 07/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 ELIZABETH PL
DAYTON OH
45417-3445
US

IV. Provider business mailing address

1 ELIZABETH PL
DAYTON OH
45417-3445
US

V. Phone/Fax

Practice location:
  • Phone: 937-813-1737
  • Fax:
Mailing address:
  • Phone: 937-813-1737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.189327
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: