Healthcare Provider Details

I. General information

NPI: 1073201034
Provider Name (Legal Business Name): JORDAN FREDERICK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2023
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3918 CLOCK POINTE TRL STE 103
STOW OH
44224-2989
US

IV. Provider business mailing address

1333 HOMESITE DR
STOW OH
44224-1231
US

V. Phone/Fax

Practice location:
  • Phone: 216-839-2273
  • Fax:
Mailing address:
  • Phone: 440-539-3258
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC.2405811
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: