MEDICARE: JACQUELINE CARSON

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	247200000X	Other Technician	401053050310	OH
2	376K00000X	Nurse's Aide	401053050310	OH

General Provider Information

NPI Number	:	1952708448
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE CARSON

Provider Business Mailing Address
First Line	:	3471 EAST 78TH STREET
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44127
Country	:	US
Telephone Number	:	216-570-7869
Fax Number	:

Provider Business Practice Location Address
First Line	:	3471 E 78TH ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44127-2018
Country	:	US
Telephone Number	:	216-570-7869
Fax Number	:

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

Provider Enumeration Date	:	11/26/2014
Last Update Date	:	11/26/2014

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Directions to “ JACQUELINE CARSON ” Practice Location

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