Provider Demographics
NPI:1871347302
Name:PONIST, JACOB AXEL (MS, LPC)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:AXEL
Last Name:PONIST
Suffix:
Gender:M
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:152 SCHILL LN
Mailing Address - Street 2:
Mailing Address - City:LUCINDA
Mailing Address - State:PA
Mailing Address - Zip Code:16235-3236
Mailing Address - Country:US
Mailing Address - Phone:814-327-5758
Mailing Address - Fax:
Practice Address - Street 1:17 S 4TH AVE
Practice Address - Street 2:
Practice Address - City:CLARION
Practice Address - State:PA
Practice Address - Zip Code:16214-1376
Practice Address - Country:US
Practice Address - Phone:814-227-7953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-12
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC017013101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional