Basic Information
| Provider Information | |||||||||
| NPI: | 1245620038 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JAKUBOWSKI | ||||||||
| FirstName: | CHAD | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | LPCC/LICDC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 429 | ||||||||
| Address2: | |||||||||
| City: | LISBON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 444320429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304249573 | ||||||||
| FaxNumber: | 3304240877 | ||||||||
| Practice Location | |||||||||
| Address1: | 40722 STATE ROUTE 154 | ||||||||
| Address2: | |||||||||
| City: | LISBON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 444328500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304249573 | ||||||||
| FaxNumber: | 3304240877 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2015 | ||||||||
| LastUpdateDate: | 02/17/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | C1300409 | OH | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | E.1600045 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Professional | 101YA0400X | LICDC.161054 | OH | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.