Provider Demographics
NPI:1902677982
Name:WARREN, JACQUELINE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:WARREN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2980 BELMONT AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44505-1834
Mailing Address - Country:US
Mailing Address - Phone:330-759-0276
Mailing Address - Fax:330-759-0030
Practice Address - Street 1:136 WESTCHESTER DR STE 5
Practice Address - Street 2:
Practice Address - City:AUSTINTOWN
Practice Address - State:OH
Practice Address - Zip Code:44515-3965
Practice Address - Country:US
Practice Address - Phone:330-270-1400
Practice Address - Fax:330-270-1404
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-10
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2305318-TRNE101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional