Healthcare Provider Details

I. General information

NPI: 1427763945
Provider Name (Legal Business Name): PATH NEUROPSYCHOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2023
Last Update Date: 03/22/2023
Certification Date: 03/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2812 MACK RD
FAIRFIELD OH
45014-5130
US

IV. Provider business mailing address

2812 MACK RD
FAIRFIELD OH
45014-5130
US

V. Phone/Fax

Practice location:
  • Phone: 513-429-9886
  • Fax:
Mailing address:
  • Phone: 513-813-5327
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. SHAWNA JACOB
Title or Position: CLINICAL PSYCHOLOGIST
Credential: PHD
Phone: 513-813-5327