Provider Demographics
NPI:1457010787
Name:FAMBRO, JESSICA L (CDCA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:FAMBRO
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1017 HERRING AVE
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44906-3910
Mailing Address - Country:US
Mailing Address - Phone:614-205-3563
Mailing Address - Fax:
Practice Address - Street 1:1017 HERRING AVE
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44906-3910
Practice Address - Country:US
Practice Address - Phone:614-205-3563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-14
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.179195101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty