Provider Demographics
NPI:1457738668
Name:HALLBOM, JANINE EMMA
Entity Type:Individual
Prefix:
First Name:JANINE
Middle Name:EMMA
Last Name:HALLBOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3676 INDEPENDENCE RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44105-7224
Mailing Address - Country:US
Mailing Address - Phone:216-978-3718
Mailing Address - Fax:
Practice Address - Street 1:3676 INDEPENDENCE RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44105-7224
Practice Address - Country:US
Practice Address - Phone:216-978-3718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-27
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0116196Medicaid