Provider Demographics
NPI:1992529432
Name:MCCLELLAN, JACOB (EDS MA)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:MCCLELLAN
Suffix:
Gender:M
Credentials:EDS MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 TRAIL DR APT 61
Mailing Address - Street 2:
Mailing Address - City:NAPOLEON
Mailing Address - State:OH
Mailing Address - Zip Code:43545-1023
Mailing Address - Country:US
Mailing Address - Phone:330-703-8430
Mailing Address - Fax:
Practice Address - Street 1:660 TRAIL DR APT 61
Practice Address - Street 2:
Practice Address - City:NAPOLEON
Practice Address - State:OH
Practice Address - Zip Code:43545-1023
Practice Address - Country:US
Practice Address - Phone:330-703-8430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-12
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH3415250103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool