Healthcare Provider Details

I. General information

NPI: 1639887185
Provider Name (Legal Business Name): TIFFANY JORDAN SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2022
Last Update Date: 03/21/2025
Certification Date: 03/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23425 COMMERCE PARK STE 104
BEACHWOOD OH
44122-5848
US

IV. Provider business mailing address

1372 CARYL DR
BEDFORD OH
44146
US

V. Phone/Fax

Practice location:
  • Phone: 216-831-2900
  • Fax: 216-831-4306
Mailing address:
  • Phone: 419-217-2884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0035137
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number452706
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: