Healthcare Provider Details

I. General information

NPI: 1518894542
Provider Name (Legal Business Name): PAYTON JADE, ENTLER ISRAEL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2026
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 MORTON ST
JACKSON OH
45640-1028
US

IV. Provider business mailing address

710 N PENNSYLVANIA AVE APT 29
WELLSTON OH
45692-1263
US

V. Phone/Fax

Practice location:
  • Phone: 740-645-7952
  • Fax: 740-645-7952
Mailing address:
  • Phone: 740-645-7549
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCAPRE.195774
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: