Provider Demographics
NPI:1215541362
Name:SOUTHERN, JACQUESE LYNNETTE
Entity type:Individual
Prefix:
First Name:JACQUESE
Middle Name:LYNNETTE
Last Name:SOUTHERN
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 1:18214 LA SALLE AVE # UP
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44119-2002
Mailing Address - Country:US
Mailing Address - Phone:216-533-0478
Mailing Address - Fax:
Practice Address - Street 1:12620 LARCHMERE BLVD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44120-1110
Practice Address - Country:US
Practice Address - Phone:216-543-0478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-06
Last Update Date:2020-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2002631101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor