Basic Information
| Provider Information | |||||||||
| NPI: | 1912551599 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DENGG | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9782 BROADVIEW RD | ||||||||
| Address2: | |||||||||
| City: | BROADVIEW HTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441473106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3305698321 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10427 DETROIT AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441021645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2166947200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2019 | ||||||||
| LastUpdateDate: | 07/31/2019 | ||||||||
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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 | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.