Provider Demographics
NPI:1952425878
Name:FEDORKA, JAMES
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:
Last Name:FEDORKA
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 1:7317 PORTAGE ST NW
Mailing Address - Street 2:
Mailing Address - City:MASSILLON
Mailing Address - State:OH
Mailing Address - Zip Code:44646-7827
Mailing Address - Country:US
Mailing Address - Phone:330-966-1620
Mailing Address - Fax:
Practice Address - Street 1:7317 PORTAGE ST NW
Practice Address - Street 2:
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44646-7827
Practice Address - Country:US
Practice Address - Phone:330-966-1620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-17
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC0000111101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional