MEDICARE: FADIA JALLAQ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	C.2204770	OH
2	101YP2500X	Professional Counselor	2103678	OH
3	106S00000X	Behavior Technician		OH
4	101YP2500X	Professional Counselor	C.2204770	OH

General Provider Information

NPI Number	:	1275073900
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FADIA JALLAQ

Provider Business Mailing Address
First Line	:	4558 HIRTH HILL RD E
Second Line	:
City	:	GROVE CITY
State	:	OH
Zip	:	43123-4512
Country	:	US
Telephone Number	:	614-965-1422
Fax Number	:

Provider Business Practice Location Address
First Line	:	4558 HIRTH HILL RD E
Second Line	:
City	:	GROVE CITY
State	:	OH
Zip	:	43123-4512
Country	:	US
Telephone Number	:	513-725-3457
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/28/2017
Last Update Date	:	09/22/2023

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