Healthcare Provider Details

I. General information

NPI: 1346079738
Provider Name (Legal Business Name): MR. JACOB GALLIGAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2024
Last Update Date: 08/01/2024
Certification Date: 08/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 MULL AVE
AKRON OH
44313-7502
US

IV. Provider business mailing address

6297 2ND AVE
KENT OH
44240-2995
US

V. Phone/Fax

Practice location:
  • Phone: 330-867-5603
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC.2305571
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: