Provider Demographics
NPI:1326653114
Name:WATKINS, JEROME A (CDCA)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:A
Last Name:WATKINS
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 1:2314 KELLY PL
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44052-4838
Mailing Address - Country:US
Mailing Address - Phone:440-246-4616
Mailing Address - Fax:440-246-4616
Practice Address - Street 1:2314 KELLY PL
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44052-4838
Practice Address - Country:US
Practice Address - Phone:440-246-4616
Practice Address - Fax:440-246-1997
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-09
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRA162262405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional