Provider Demographics
NPI:1063926194
Name:MCCOMBS, JACQUELYN R (QMHS, LCDC III)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:R
Last Name:MCCOMBS
Suffix:
Gender:F
Credentials:QMHS, LCDC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:662 KINGSFORD RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43204-1116
Mailing Address - Country:US
Mailing Address - Phone:614-804-9668
Mailing Address - Fax:
Practice Address - Street 1:5665 HOOVER RD
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:OH
Practice Address - Zip Code:43123-9280
Practice Address - Country:US
Practice Address - Phone:614-875-2371
Practice Address - Fax:614-875-2116
Is Sole Proprietor?:No
Enumeration Date:2017-11-28
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
OHLCDCII.161593101YA0400X
OH171M00000X
OHLCDCIII.161969101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0065539Medicaid