Provider Demographics
NPI:1427829076
Name:EDGELL, JACOB W
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:W
Last Name:EDGELL
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 1:873 ROBINSON AVE
Mailing Address - Street 2:
Mailing Address - City:BARBERTON
Mailing Address - State:OH
Mailing Address - Zip Code:44203-3704
Mailing Address - Country:US
Mailing Address - Phone:330-696-2620
Mailing Address - Fax:
Practice Address - Street 1:873 ROBINSON AVE
Practice Address - Street 2:
Practice Address - City:BARBERTON
Practice Address - State:OH
Practice Address - Zip Code:44203-3704
Practice Address - Country:US
Practice Address - Phone:330-696-2620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-12
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide