Provider Demographics
NPI:1881194405
Name:SOPKOVICH, JASON CARL (LCDCIII)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:CARL
Last Name:SOPKOVICH
Suffix:
Gender:M
Credentials:LCDCIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1127 CARNEGIE AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44115-2805
Mailing Address - Country:US
Mailing Address - Phone:216-861-4246
Mailing Address - Fax:216-861-1156
Practice Address - Street 1:1127 CARNEGIE AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44115-2805
Practice Address - Country:US
Practice Address - Phone:216-861-4246
Practice Address - Fax:216-861-1156
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-20
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OHLCDCIII.161815101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No171M00000XOther Service ProvidersCase Manager/Care Coordinator