Healthcare Provider Details

I. General information

NPI: 1174078638
Provider Name (Legal Business Name): JENNIVIERE HOMITZ-DANIELS PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2016
Last Update Date: 10/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8701 MENTOR AVE
MENTOR OH
44060-6103
US

IV. Provider business mailing address

8701 MENTOR AVE
MENTOR OH
44060-6103
US

V. Phone/Fax

Practice location:
  • Phone: 440-266-0770
  • Fax: 440-266-0257
Mailing address:
  • Phone: 440-266-0770
  • Fax: 440-266-0257

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number393799
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: