Provider Demographics
NPI:1306206487
Name:PELSER, JACQUES (LPCC-S, LIDCD)
Entity Type:Individual
Prefix:
First Name:JACQUES
Middle Name:
Last Name:PELSER
Suffix:
Gender:M
Credentials:LPCC-S, LIDCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 CLEVELAND AVE NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44702-1805
Mailing Address - Country:US
Mailing Address - Phone:330-455-0374
Mailing Address - Fax:330-453-6716
Practice Address - Street 1:1680 NAVE RD SE
Practice Address - Street 2:
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44646-9604
Practice Address - Country:US
Practice Address - Phone:330-830-8740
Practice Address - Fax:330-830-0912
Is Sole Proprietor?:No
Enumeration Date:2016-03-02
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLICDC.161995101YA0400X
OHE.1901301-SUPV101YP2500X, 101YP2500X
OHE190301101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0266616Medicaid