Healthcare Provider Details

I. General information

NPI: 1366959413
Provider Name (Legal Business Name): JENNIFER ELLEN CARTER CDCA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER ELLEN CARTER CDCA

II. Dates (important events)

Enumeration Date: 01/10/2018
Last Update Date: 09/07/2022
Certification Date: 09/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6400 E BROAD ST FL 4
COLUMBUS OH
43213-2086
US

IV. Provider business mailing address

8145 N MAIN ST
DAYTON OH
45415-1703
US

V. Phone/Fax

Practice location:
  • Phone: 937-228-0579
  • Fax: 937-641-8517
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.164950
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: