Provider Demographics
NPI:1730885419
Name:DAVISON, JAZMONE
Entity type:Individual
Prefix:
First Name:JAZMONE
Middle Name:
Last Name:DAVISON
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:PO BOX 35521
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44735-5521
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:216-412-8080
Practice Address - Street 1:4368 DRESSLER RD NW STE 201B
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-2772
Practice Address - Country:US
Practice Address - Phone:330-284-2856
Practice Address - Fax:330-830-6534
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-03
Last Update Date:2025-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374943163W00000X
251C00000X, 320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No163W00000XNursing Service ProvidersRegistered Nurse
No251C00000XAgenciesDay Training, Developmentally Disabled Services