Provider Demographics
NPI:1063285658
Name:SOUDAH, JACOB M
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:M
Last Name:SOUDAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2875 OLENTANGY RIVER RD APT 610
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-3514
Mailing Address - Country:US
Mailing Address - Phone:614-772-3517
Mailing Address - Fax:
Practice Address - Street 1:246 E CAMPUS VIEW BLVD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43235-4634
Practice Address - Country:US
Practice Address - Phone:614-505-3126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-06
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH186292101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)