Provider Demographics
NPI:1659002939
Name:KYAGILO, JACQUES KYANZA SR
Entity Type:Individual
Prefix:
First Name:JACQUES
Middle Name:KYANZA
Last Name:KYAGILO
Suffix:SR
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 1:19220 VAN AKEN BLVD APT 303
Mailing Address - Street 2:
Mailing Address - City:SHAKER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44122-3557
Mailing Address - Country:US
Mailing Address - Phone:832-258-7367
Mailing Address - Fax:
Practice Address - Street 1:19220 VAN AKEN BLVD APT 303
Practice Address - Street 2:
Practice Address - City:SHAKER HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44122-3557
Practice Address - Country:US
Practice Address - Phone:832-258-7367
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-18
Last Update Date:2022-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral