Healthcare Provider Details

I. General information

NPI: 1063926194
Provider Name (Legal Business Name): JACQUELYN R MCCOMBS QMHS, LCDC III, LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2017
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5665 HOOVER RD
GROVE CITY OH
43123-9280
US

IV. Provider business mailing address

662 KINGSFORD RD
COLUMBUS OH
43204-1116
US

V. Phone/Fax

Practice location:
  • Phone: 614-875-2371
  • Fax: 614-875-2116
Mailing address:
  • Phone: 614-804-9668
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCDCII.161593
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCDCIII.161969
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.2614806
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: