Provider Demographics
NPI:1437679743
Name:PANGALLO, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:PANGALLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 CHAPEL RD
Mailing Address - Street 2:
Mailing Address - City:AMELIA
Mailing Address - State:OH
Mailing Address - Zip Code:45102-1709
Mailing Address - Country:US
Mailing Address - Phone:513-604-0702
Mailing Address - Fax:
Practice Address - Street 1:117 CHAPEL RD
Practice Address - Street 2:
Practice Address - City:AMELIA
Practice Address - State:OH
Practice Address - Zip Code:45102
Practice Address - Country:US
Practice Address - Phone:513-604-0702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer