Provider Demographics
NPI:1538582044
Name:CRESCENZO, JACQUELYN
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:CRESCENZO
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 1:958 LONGBROOK DR
Mailing Address - Street 2:
Mailing Address - City:WADSWORTH
Mailing Address - State:OH
Mailing Address - Zip Code:44281-8814
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:958 LONGBROOK DR
Practice Address - Street 2:
Practice Address - City:WADSWORTH
Practice Address - State:OH
Practice Address - Zip Code:44281-8814
Practice Address - Country:US
Practice Address - Phone:330-361-0723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-04
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH3021993103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool