Healthcare Provider Details

I. General information

NPI: 1962055814
Provider Name (Legal Business Name): JENNIFER HAKE CDCA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2019
Last Update Date: 06/11/2025
Certification Date: 06/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 BOARDMAN CANFIELD RD
BOARDMAN OH
44512-4218
US

IV. Provider business mailing address

2841 VESTAL RD
YOUNGSTOWN OH
44509
US

V. Phone/Fax

Practice location:
  • Phone: 330-953-0243
  • Fax:
Mailing address:
  • Phone: 330-953-0243
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.170280
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: