Healthcare Provider Details

I. General information

NPI: 1669050373
Provider Name (Legal Business Name): JENNIFER L GROOMS CDCA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2021
Last Update Date: 05/03/2022
Certification Date: 05/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2115 W PARK DR
LORAIN OH
44053-1138
US

IV. Provider business mailing address

6136 W RIVER RD S
ELYRIA OH
44035-5432
US

V. Phone/Fax

Practice location:
  • Phone: 440-989-4900
  • Fax:
Mailing address:
  • Phone: 440-258-8452
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCDCII.161781
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.175731
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: