Healthcare Provider Details

I. General information

NPI: 1154712693
Provider Name (Legal Business Name): JACOB TELEGO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2015
Last Update Date: 03/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8440 MARKET ST
BOARDMAN OH
44512-6702
US

IV. Provider business mailing address

8440 MARKET ST
BOARDMAN OH
44512-6702
US

V. Phone/Fax

Practice location:
  • Phone: 330-965-9999
  • Fax: 330-757-0000
Mailing address:
  • Phone: 330-965-9999
  • Fax: 330-757-0000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC.1300359
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: