=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407353709
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAI JACKSON QMHS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2018
-----------------------------------------------------
Last Update Date | 11/16/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13422 KINSMAN RD
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44120-4410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-283-4400
-----------------------------------------------------
Fax | 216-283-5359
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17210 DEFOREST AVE
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44128-2516
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-283-4400
-----------------------------------------------------
Fax | 216-283-5359
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------