Healthcare Provider Details

I. General information

NPI: 1083125918
Provider Name (Legal Business Name): TORREAN DARNELL JACKSON CDCA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2017
Last Update Date: 09/29/2020
Certification Date: 09/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 MARMION AVE
YOUNGSTOWN OH
44502-2323
US

IV. Provider business mailing address

535 MARMION AVE
YOUNGSTOWN OH
44502-2323
US

V. Phone/Fax

Practice location:
  • Phone: 330-782-5664
  • Fax:
Mailing address:
  • Phone: 330-782-5664
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA172985
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number401563210813
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: