Provider Demographics
NPI:1629788732
Name:VILLALTA, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:VILLALTA
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 1:14986 BUNDYSBURG RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44062-9778
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14986 BUNDYSBURG RD
Practice Address - Street 2:
Practice Address - City:MIDDLEFIELD
Practice Address - State:OH
Practice Address - Zip Code:44062-9778
Practice Address - Country:US
Practice Address - Phone:440-313-7922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-29
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician