MEDICARE: JESSICA KING

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	E.2102072	OH

General Provider Information

NPI Number	:	1700476751
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA KING

Provider Business Mailing Address
First Line	:	PO BOX 24242
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44124-0242
Country	:	US
Telephone Number	:	216-839-2273
Fax Number	:

Provider Business Practice Location Address
First Line	:	3918 CLOCK POINTE TRL STE 104
Second Line	:
City	:	STOW
State	:	OH
Zip	:	44224-2989
Country	:	US
Telephone Number	:	216-839-2273
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/24/2021
Last Update Date	:	01/28/2021

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