Provider Demographics
NPI:1447652730
Name:SURA, JACQUELINE
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:
Last Name:SURA
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 1:2733 E 12TH ST STE C2
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-4672
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7580 NORTHCLIFF AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:OH
Practice Address - Zip Code:44144-3270
Practice Address - Country:US
Practice Address - Phone:248-846-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-18
Last Update Date:2025-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOBA.107103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst