Healthcare Provider Details

I. General information

NPI: 1821582776
Provider Name (Legal Business Name): ROBIN ELAINE JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2018
Last Update Date: 12/20/2024
Certification Date: 12/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 WHITNEY DR STE 122
MILFORD OH
45150-8400
US

IV. Provider business mailing address

6460 HARRISON AVE STE 200
CINCINNATI OH
45247-7958
US

V. Phone/Fax

Practice location:
  • Phone: 513-941-4999
  • Fax: 513-694-0168
Mailing address:
  • Phone: 513-941-4999
  • Fax: 513-694-0168

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCDCIII.162469
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCDCII.161636
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.166828
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.162999
License Number StateOH
# 5
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC.2405498-TRNE
License Number StateOH
# 6
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC.2406666
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: