Provider Demographics
NPI:1457332660
Name:JERDONEK, PAUL M (PHD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:M
Last Name:JERDONEK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3591 RESERVE COMMONS DR STE 301
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-5334
Mailing Address - Country:US
Mailing Address - Phone:330-764-7916
Mailing Address - Fax:330-723-6399
Practice Address - Street 1:8748 BRECKSVILLE RD
Practice Address - Street 2:STE 222
Practice Address - City:BRECKSVILLE
Practice Address - State:OH
Practice Address - Zip Code:44141-1985
Practice Address - Country:US
Practice Address - Phone:216-839-2273
Practice Address - Fax:216-896-0735
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3609103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0382036Medicaid
OHJECP 19701Medicare ID - Type Unspecified