Basic Information
| Provider Information | |||||||||
| NPI: | 1649760042 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IREY | ||||||||
| FirstName: | JACOB | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1662 MARS AVE | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441073825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162823838 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1662 MARS AVE | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441073825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162823838 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2018 | ||||||||
| LastUpdateDate: | 09/09/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | OH | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 0287342 | 05 | OH | MEDICAID |