Provider Demographics
NPI:1396309266
Name:JACOBS, JOSHUA (CDCA II)
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:JACOBS
Suffix:
Gender:M
Credentials:CDCA II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4075 VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44109-3072
Mailing Address - Country:US
Mailing Address - Phone:216-313-1903
Mailing Address - Fax:
Practice Address - Street 1:4075 VALLEY RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44109-3072
Practice Address - Country:US
Practice Address - Phone:216-313-1903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-26
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH543Medicaid