Basic Information
| Provider Information | |||||||||
| NPI: | 1508306382 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CROSBY | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | |||||||||
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| Credential: | LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 347 MIDWAY BLVD | ||||||||
| Address2: | |||||||||
| City: | ELYRIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440359006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403245701 | ||||||||
| FaxNumber: | 4403249978 | ||||||||
| Practice Location | |||||||||
| Address1: | 347 MIDWAY BLVD | ||||||||
| Address2: | |||||||||
| City: | ELYRIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440359006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403245701 | ||||||||
| FaxNumber: | 4403249978 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2017 | ||||||||
| LastUpdateDate: | 02/28/2017 | ||||||||
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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 | 104100000X | S.1450780 | OH | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.