Healthcare Provider Details

I. General information

NPI: 1164965166
Provider Name (Legal Business Name): JAKE SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2016
Last Update Date: 11/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 WALL ST STE F
CINCINNATI OH
45212-2794
US

IV. Provider business mailing address

2300 WALL ST STE F
CINCINNATI OH
45212-2794
US

V. Phone/Fax

Practice location:
  • Phone: 513-834-7063
  • Fax: 513-429-4939
Mailing address:
  • Phone: 513-834-7063
  • Fax: 513-429-4939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.162038
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: