Provider Demographics
NPI:1760484695
Name:CLICK, JACOB D III (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:D
Last Name:CLICK
Suffix:III
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 80690
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44708-0690
Mailing Address - Country:US
Mailing Address - Phone:330-363-7444
Mailing Address - Fax:330-363-7770
Practice Address - Street 1:2600 6TH ST SW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44710-1702
Practice Address - Country:US
Practice Address - Phone:330-363-7462
Practice Address - Fax:330-363-7679
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-11
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH254993367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2359059Medicaid
OHCL8230934Medicare ID - Type Unspecified