MEDICARE: PROF. JACQUELINE T DOODLEY OCPRS

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	175T00000X	Peer Specialist	01249	OH

General Provider Information

NPI Number	:	1942848619
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PROF. JACQUELINE T DOODLEY OCPRS

Provider Business Mailing Address
First Line	:	2475 PERDUE AVE
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43211-1876
Country	:	US
Telephone Number	:	614-440-2737
Fax Number	:

Provider Business Practice Location Address
First Line	:	2475 PERDUE AVE
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43211-1876
Country	:	US
Telephone Number	:	614-440-2737
Fax Number	:

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

Provider Enumeration Date	:	12/12/2019
Last Update Date	:	12/12/2019

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