Provider Demographics
NPI:1619510526
Name:ACKERMAN, JARRETH
Entity Type:Individual
Prefix:
First Name:JARRETH
Middle Name:
Last Name:ACKERMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JAY
Other - Middle Name:
Other - Last Name:ACKERMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1212
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44482-1212
Mailing Address - Country:US
Mailing Address - Phone:304-696-8223
Mailing Address - Fax:330-294-5641
Practice Address - Street 1:1212 TOD PL NW
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44485-2475
Practice Address - Country:US
Practice Address - Phone:330-469-6822
Practice Address - Fax:330-294-5641
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-23
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH001173175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist