=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518979962
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KARI M JACONO MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/13/2006
-----------------------------------------------------
Last Update Date | 11/20/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3600 KOLBE RD STE 120
-----------------------------------------------------
City | LORAIN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44053-1652
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-282-7408
-----------------------------------------------------
Fax | 440-690-2214
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 8792
-----------------------------------------------------
City | BELFAST
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04915-8792
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-282-7408
-----------------------------------------------------
Fax | 440-690-2214
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 35084438
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 35-084438
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------