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General NPI Number Information
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NPI Number | 1457940736
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Entity Type | Individual
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Provider Name | JARRAD MICHAEL THACKER CDCA.173952
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Gender | Male
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Dates
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Enumeration Date | 01/12/2021
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Last Update Date | 01/12/2021
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Provider Practice Location Address
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Address Line | 4968 GLENWAY AVE
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City | CINCINNATI
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State | OH
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Zip | 45238-3902
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Country | US
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Telephone | 513-853-6575
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Fax |
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Provider Business Mailing Address
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Address Line | 1494 BEACON ST APT 3
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City | CINCINNATI
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State | OH
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Zip | 45230-2857
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Country | US
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Telephone | 513-314-0708
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | CDCA.173952
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License Number State | OH
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