Provider Demographics
NPI:1831827807
Name:HOOVER, JACK M (CDCA)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:M
Last Name:HOOVER
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10098 HILLCREST RD
Mailing Address - Street 2:
Mailing Address - City:KIRTLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44094-9539
Mailing Address - Country:US
Mailing Address - Phone:330-327-8517
Mailing Address - Fax:
Practice Address - Street 1:10098 HILLCREST RD
Practice Address - Street 2:
Practice Address - City:KIRTLAND
Practice Address - State:OH
Practice Address - Zip Code:44094-9539
Practice Address - Country:US
Practice Address - Phone:330-327-8517
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-09
Last Update Date:2024-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLCDCII.161978101YA0400X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)