MEDICARE: JESSICA LYNN LAROCCO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	175T00000X	Peer Specialist		OH

General Provider Information

NPI Number	:	1598418790
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA LYNN LAROCCO

Provider Business Mailing Address
First Line	:	19181 LAKE SHORE BLVD
Second Line	:
City	:	EUCLID
State	:	OH
Zip	:	44119-1048
Country	:	US
Telephone Number	:	330-367-9737
Fax Number	:

Provider Business Practice Location Address
First Line	:	19181 LAKE SHORE BLVD
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44119-1048
Country	:	US
Telephone Number	:	330-367-9737
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/28/2022
Last Update Date	:	01/28/2022

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