Provider Demographics
NPI:1679064497
Name:IACOBUCCI, JANINE (OCPSA)
Entity Type:Individual
Prefix:
First Name:JANINE
Middle Name:
Last Name:IACOBUCCI
Suffix:
Gender:F
Credentials:OCPSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:527 N MERIDIAN RD
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44509-1227
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:527 N MERIDIAN RD
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44509-1227
Practice Address - Country:US
Practice Address - Phone:330-797-0074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-29
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
OHOCPSA.161562405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional
No251S00000XAgenciesCommunity/Behavioral Health