Provider Demographics
NPI:1700959285
Name:JACOB, MARY CATHERINE - (RNC, PC)
Entity Type:Individual
Prefix:MS
First Name:MARY CATHERINE
Middle Name:-
Last Name:JACOB
Suffix:
Gender:F
Credentials:RNC, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4293 VIRGINIA DR
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW PARK
Mailing Address - State:OH
Mailing Address - Zip Code:44126-1755
Mailing Address - Country:US
Mailing Address - Phone:440-356-1190
Mailing Address - Fax:
Practice Address - Street 1:14843 W SPRAGUE RD
Practice Address - Street 2:SUITE A
Practice Address - City:STRONGSVILLE
Practice Address - State:OH
Practice Address - Zip Code:44136-1754
Practice Address - Country:US
Practice Address - Phone:440-234-9955
Practice Address - Fax:440-234-5994
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC0006576101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health