Provider Demographics
NPI:1013378447
Name:KOVACIK, JEROME EDWARD (CDCA)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:EDWARD
Last Name:KOVACIK
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 KENNY CT
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:OH
Mailing Address - Zip Code:45150-1626
Mailing Address - Country:US
Mailing Address - Phone:513-485-5082
Mailing Address - Fax:
Practice Address - Street 1:7 KENNY CT
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:OH
Practice Address - Zip Code:45150-1626
Practice Address - Country:US
Practice Address - Phone:513-485-5082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-12
Last Update Date:2016-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH140335101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)