Healthcare Provider Details

I. General information

NPI: 1942939111
Provider Name (Legal Business Name): JORDAN BONNER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2022
Last Update Date: 11/01/2024
Certification Date: 11/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 E 45TH ST STE 116
CLEVELAND OH
44127-1094
US

IV. Provider business mailing address

20829 MILLER AVE
CLEVELAND OH
44119-2318
US

V. Phone/Fax

Practice location:
  • Phone: 216-526-1600
  • Fax:
Mailing address:
  • Phone: 440-840-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: