Provider Demographics
NPI:1790235109
Name:FORD, JEROMY (AOD/SUD)
Entity Type:Individual
Prefix:
First Name:JEROMY
Middle Name:
Last Name:FORD
Suffix:
Gender:M
Credentials:AOD/SUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:266 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92570-2011
Mailing Address - Country:US
Mailing Address - Phone:951-956-5373
Mailing Address - Fax:
Practice Address - Street 1:226 W. 4TH ST
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92570
Practice Address - Country:US
Practice Address - Phone:951-602-5886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-10
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)