Provider Demographics
NPI:1811738651
Name:TRIFONOFF, JACCOB
Entity type:Individual
Prefix:
First Name:JACCOB
Middle Name:
Last Name:TRIFONOFF
Suffix:
Gender:U
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 KINGSTON AVE
Mailing Address - Street 2:
Mailing Address - City:STEUBENVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43952-1035
Mailing Address - Country:US
Mailing Address - Phone:740-275-1088
Mailing Address - Fax:
Practice Address - Street 1:214 KINGSTON AVE
Practice Address - Street 2:
Practice Address - City:STEUBENVILLE
Practice Address - State:OH
Practice Address - Zip Code:43952-1035
Practice Address - Country:US
Practice Address - Phone:740-275-1088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-05
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)