Healthcare Provider Details

I. General information

NPI: 1306206487
Provider Name (Legal Business Name): JACQUES PELSER LPCC-S, LIDCD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2016
Last Update Date: 07/07/2022
Certification Date: 07/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1680 NAVE RD SE
MASSILLON OH
44646-9604
US

IV. Provider business mailing address

625 CLEVELAND AVE NW
CANTON OH
44702-1805
US

V. Phone/Fax

Practice location:
  • Phone: 330-830-8740
  • Fax: 330-830-0912
Mailing address:
  • Phone: 330-455-0374
  • Fax: 330-453-6716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLICDC.161995
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberE.1901301-SUPV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: