Provider Demographics
NPI:1881380111
Name:AZZAWI, JACOB ZACHARIAH
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:ZACHARIAH
Last Name:AZZAWI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6610 CHAFFEE CT APT E-5
Mailing Address - Street 2:
Mailing Address - City:BRECKSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44141-2489
Mailing Address - Country:US
Mailing Address - Phone:216-527-6084
Mailing Address - Fax:
Practice Address - Street 1:169 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13905-4246
Practice Address - Country:US
Practice Address - Phone:216-527-6084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-11
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty