Provider Demographics
NPI:1679221949
Name:OBERHOLTZER, JORDAN ELIZABETH
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:ELIZABETH
Last Name:OBERHOLTZER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:686 PERRY ST
Mailing Address - Street 2:
Mailing Address - City:VERMILION
Mailing Address - State:OH
Mailing Address - Zip Code:44089-1162
Mailing Address - Country:US
Mailing Address - Phone:440-522-9381
Mailing Address - Fax:
Practice Address - Street 1:312 3RD ST
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-5618
Practice Address - Country:US
Practice Address - Phone:440-323-5707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-15
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health