Healthcare Provider Details

I. General information

NPI: 1942872254
Provider Name (Legal Business Name): JESSICA GAZELLA LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2021
Last Update Date: 07/15/2021
Certification Date: 07/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

273 E JACKSON ST
PAINESVILLE OH
44077-4042
US

IV. Provider business mailing address

5445 SMITH RD
BROOKPARK OH
44142-2026
US

V. Phone/Fax

Practice location:
  • Phone: 440-709-0053
  • Fax:
Mailing address:
  • Phone: 216-453-1112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2106035
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: