Provider Demographics
NPI:1588770622
Name:BERK, JAY HOWARD (PHD)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:HOWARD
Last Name:BERK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28001 CHAGRIN BLVD
Mailing Address - Street 2:SUITE 212
Mailing Address - City:WOODMERE
Mailing Address - State:OH
Mailing Address - Zip Code:44122-4559
Mailing Address - Country:US
Mailing Address - Phone:216-292-7170
Mailing Address - Fax:216-292-7182
Practice Address - Street 1:28001 CHAGRIN BLVD
Practice Address - Street 2:SUITE 212
Practice Address - City:WOODMERE
Practice Address - State:OH
Practice Address - Zip Code:44122-4559
Practice Address - Country:US
Practice Address - Phone:216-292-7170
Practice Address - Fax:216-292-7182
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4737103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0966807Medicaid
OH0966807Medicaid