Provider Demographics
NPI:1568813160
Name:JAKUBOWSKI, LAUREN
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:JAKUBOWSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24200 CHAGRIN BLVD
Mailing Address - Street 2:
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5550
Mailing Address - Country:US
Mailing Address - Phone:216-831-6466
Mailing Address - Fax:216-766-6084
Practice Address - Street 1:24200 CHAGRIN BLVD
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-5550
Practice Address - Country:US
Practice Address - Phone:216-831-6466
Practice Address - Fax:216-766-6084
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-24
Last Update Date:2016-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.1300744251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9166922Medicare PIN