Individual
DOMINIQUE SHAVANTA JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
4114 E 141ST ST, CLEVELAND, OH 44128-1806
(216) 501-3289
Mailing address
4114 E 141ST ST, CLEVELAND, OH 44128-1806
(216) 501-3289
Taxonomy
Speciality
Code
Description
License number
State
171M00000X
Case Manager/Care Coordinator
—
—
175T00000X
Peer Specialist
Primary
APS.005574
OH
372600000X
Adult Companion
—
—
376K00000X
Nurse's Aide
—
—
Other
Enumeration date
04/02/2024
Last updated
12/02/2024
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