Provider Demographics
NPI:1972351484
Name:MIRACLE, JAKE
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:MIRACLE
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 1:4898 WALDAMERE AVE
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094-5771
Mailing Address - Country:US
Mailing Address - Phone:440-856-5727
Mailing Address - Fax:
Practice Address - Street 1:4898 WALDAMERE AVE
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-5771
Practice Address - Country:US
Practice Address - Phone:440-856-5727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-09
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach