Healthcare Provider Details

I. General information

NPI: 1073385407
Provider Name (Legal Business Name): MRS. KOURTNEY JARAE FORD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2023
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8100 SOUTH ST SE
WARREN OH
44484-2445
US

IV. Provider business mailing address

2359 KNOLLWOOD AVE
YOUNGSTOWN OH
44514-1525
US

V. Phone/Fax

Practice location:
  • Phone: 216-260-1405
  • Fax: 330-632-8823
Mailing address:
  • Phone: 216-260-1405
  • Fax: 330-632-8823

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: