Provider Demographics
NPI:1891320727
Name:CRAFT, JERRY
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:CRAFT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:529 GLENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:NEW BOSTON
Mailing Address - State:OH
Mailing Address - Zip Code:45662-5504
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1616 GRANT ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-3663
Practice Address - Country:US
Practice Address - Phone:740-901-0416
Practice Address - Fax:740-901-0417
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-11
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 101YM0800X
OHCDCA.174908101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0400089Medicaid