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General NPI Number Information
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NPI Number | 1396397527
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Entity Type | Individual
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Provider Name | JACOB B GILMORE LCDC III
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Gender | Male
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Dates
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Enumeration Date | 07/09/2019
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Last Update Date | 03/07/2025
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Provider Practice Location Address
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Address Line | 4930 ENTERPRISE DR NW
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City | WARREN
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State | OH
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Zip | 44481-8706
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Country | US
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Telephone | 330-787-0955
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Fax |
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Provider Business Mailing Address
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Address Line | 4930 ENTERPRISE DR NW
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City | WARREN
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State | OH
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Zip | 44481-8706
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Country | US
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Telephone | 330-787-0955
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number | 170920
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | LCDCIII162380
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License Number State | OH
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