Basic Information
| Provider Information | |||||||||
| NPI: | 1083074983 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WARSZAWSKI | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | LEW | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 68 W CHURCH ST | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430555050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7402811777 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 68 W CHURCH ST | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430555050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7402811777 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2016 | ||||||||
| LastUpdateDate: | 03/07/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 02/21/2019 | ||||||||
| NPIReactivationDate: | 03/01/2019 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.