Healthcare Provider Details

I. General information

NPI: 1174297055
Provider Name (Legal Business Name): JENNIFER NICOLE ZACKASEE LSW, MSW, CDCA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2021
Last Update Date: 08/04/2021
Certification Date: 08/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11369 MARKET ST
NORTH LIMA OH
44452-9782
US

IV. Provider business mailing address

11369 MARKET ST
NORTH LIMA OH
44452-9782
US

V. Phone/Fax

Practice location:
  • Phone: 330-965-9999
  • Fax: 330-757-0000
Mailing address:
  • Phone: 330-965-9999
  • Fax: 330-757-0000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.174489
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberS.2106420
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: