=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962028217
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JR GATT, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2020
-----------------------------------------------------
Last Update Date | 10/20/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 430 READING RD STE 300
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45202-1460
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-499-1765
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8425 COTTONWOOD DR APT 3
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45231-5930
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-499-1765
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JERALYN BOYD
-----------------------------------------------------
Credential | LISW
-----------------------------------------------------
Telephone | 513-499-1765
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------