Provider Demographics
NPI:1912551599
Name:DENGG, JACOB A
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:A
Last Name:DENGG
Suffix:
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 1:9782 BROADVIEW RD
Mailing Address - Street 2:
Mailing Address - City:BROADVIEW HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44147-3106
Mailing Address - Country:US
Mailing Address - Phone:330-569-8321
Mailing Address - Fax:
Practice Address - Street 1:10427 DETROIT AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44102-1645
Practice Address - Country:US
Practice Address - Phone:216-694-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-31
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health