Healthcare Provider Details

I. General information

NPI: 1164068524
Provider Name (Legal Business Name): JORDAN COMMUNITY RESIDENTIAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2019
Last Update Date: 02/04/2025
Certification Date: 02/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30841 EUCLID AVE STE 103
WILLOUGHBY OH
44094-3100
US

IV. Provider business mailing address

30841 EUCLID AVE STE 103
WILLOUGHBY OH
44094-3100
US

V. Phone/Fax

Practice location:
  • Phone: 216-441-2496
  • Fax: 216-634-9611
Mailing address:
  • Phone: 216-441-2496
  • Fax: 216-634-9611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State

VIII. Authorized Official

Name: MS. TENISHA GANT
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 216-441-2496