Provider Demographics
NPI:1770132300
Name:CHMARA, JACOB SAMUEL (LLP)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:SAMUEL
Last Name:CHMARA
Suffix:
Gender:M
Credentials:LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23551 ONEIDA ST
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-3701
Mailing Address - Country:US
Mailing Address - Phone:248-330-4129
Mailing Address - Fax:
Practice Address - Street 1:1603 E 9 MILE RD
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:MI
Practice Address - Zip Code:48220-2065
Practice Address - Country:US
Practice Address - Phone:248-514-4955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-06
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6361007813103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical