Provider Demographics
NPI:1164068524
Name:JORDAN COMMUNITY RESIDENTIAL
Entity Type:Organization
Organization Name:JORDAN COMMUNITY RESIDENTIAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:TENISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:GANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-441-2496
Mailing Address - Street 1:30841 EUCLID AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094-3100
Mailing Address - Country:US
Mailing Address - Phone:216-441-2496
Mailing Address - Fax:216-634-9611
Practice Address - Street 1:30841 EUCLID AVE STE 103
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-3100
Practice Address - Country:US
Practice Address - Phone:216-441-2496
Practice Address - Fax:216-634-9611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-20
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Multi-Specialty