Individual
JACQUESE LYNNETTE SOUTHERN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
12620 LARCHMERE BLVD, CLEVELAND, OH 44120-1110
(216) 543-0478
Mailing address
18214 LA SALLE AVE # UP, CLEVELAND, OH 44119-2002
(216) 533-0478
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
Primary
C.2002631
OH
Other
Enumeration date
09/06/2020
Last updated
09/06/2020
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