Healthcare Provider Details

I. General information

NPI: 1750706677
Provider Name (Legal Business Name): JONAH LAKIN PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2014
Last Update Date: 07/04/2020
Certification Date: 07/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19220 LORAIN RD STE 203
FAIRVIEW PARK OH
44126-1976
US

IV. Provider business mailing address

19220 LORAIN RD STE 203
FAIRVIEW PARK OH
44126-1976
US

V. Phone/Fax

Practice location:
  • Phone: 216-393-7749
  • Fax:
Mailing address:
  • Phone: 216-393-7749
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number26269
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberP.07764
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: