Provider Demographics
NPI:1497254239
Name:FOFRICH, JEREMY (CDCA)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:FOFRICH
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 1:2005 ASHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43620-1703
Mailing Address - Country:US
Mailing Address - Phone:419-841-7701
Mailing Address - Fax:
Practice Address - Street 1:905 NEBRASKA AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43607-4222
Practice Address - Country:US
Practice Address - Phone:419-841-7701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-07
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.161343171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator