Provider Demographics
NPI:1952030660
Name:STREETER, JAKE DELANO SR
Entity Type:Individual
Prefix:MR
First Name:JAKE
Middle Name:DELANO
Last Name:STREETER
Suffix:SR
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 1:1063 PIERMONT RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44121-2934
Mailing Address - Country:US
Mailing Address - Phone:216-200-0627
Mailing Address - Fax:
Practice Address - Street 1:1293 COPLEY RD
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44320-2766
Practice Address - Country:US
Practice Address - Phone:330-374-1199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-08
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2204089-TRNE101YM0800X
OHC.2305290101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health