Healthcare Provider Details

I. General information

NPI: 1013414127
Provider Name (Legal Business Name): JASON ROBERT CARMODY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2018
Last Update Date: 02/11/2021
Certification Date: 02/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2210 S RIDGE RD E
ASHTABULA OH
44004-4459
US

IV. Provider business mailing address

615 ELSINORE PL STE 300
CINCINNATI OH
45202-1475
US

V. Phone/Fax

Practice location:
  • Phone: 513-834-7063
  • Fax:
Mailing address:
  • Phone: 513-834-7063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number141304
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: