Provider Demographics
NPI:1679044689
Name:JOSEPH, JACOB D (LSW)
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:D
Last Name:JOSEPH
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:799 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45804-1519
Mailing Address - Country:US
Mailing Address - Phone:567-242-6047
Mailing Address - Fax:419-227-0025
Practice Address - Street 1:799 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45804-1519
Practice Address - Country:US
Practice Address - Phone:567-242-6047
Practice Address - Fax:419-227-0025
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.0900775104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty