Provider Demographics
NPI:1053981332
Name:BOYLE, JACQUELINE ANN (LCDC III, BA)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ANN
Last Name:BOYLE
Suffix:
Gender:F
Credentials:LCDC III, BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 W MARKET ST
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44313
Mailing Address - Country:US
Mailing Address - Phone:855-747-4673
Mailing Address - Fax:
Practice Address - Street 1:1815 WEST MARKET ST
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44313-1459
Practice Address - Country:US
Practice Address - Phone:855-747-4673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-29
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
OHLCDCIII.162510101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No172V00000XOther Service ProvidersCommunity Health Worker