Provider Demographics
NPI:1669039145
Name:JAYARAJ, POONGOTHAI G (LSW)
Entity Type:Individual
Prefix:
First Name:POONGOTHAI
Middle Name:G
Last Name:JAYARAJ
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2115 W PARK DR
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44053-1138
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2121 W 117TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44111-1642
Practice Address - Country:US
Practice Address - Phone:216-417-4831
Practice Address - Fax:216-417-0040
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-21
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS1101655104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0371424Medicaid