=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477020816
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MS. KIM WILLICIA JONES
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2018
-----------------------------------------------------
Last Update Date | 06/07/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3500 CARNEGIE AVE
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44115-2641
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-260-8300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 30951 LAKE SHORE BLVD
-----------------------------------------------------
City | WILLOWICK
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44095-3616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-310-0794
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 161929
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 175T00000X
-----------------------------------------------------
Taxonomy Name | Peer Specialist
-----------------------------------------------------
License Number | 00667
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------