Provider Demographics
NPI:1255719639
Name:JEROME, RUTH (MACCC/SLP)
Entity type:Individual
Prefix:
First Name:RUTH
Middle Name:
Last Name:JEROME
Suffix:
Gender:F
Credentials:MACCC/SLP
Other - Prefix:
Other - First Name:RUTH
Other - Middle Name:
Other - Last Name:JEROME-FULTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MACCC/SLP
Mailing Address - Street 1:4768 LITCHFIELD DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44143-1487
Mailing Address - Country:US
Mailing Address - Phone:443-773-3767
Mailing Address - Fax:216-901-2803
Practice Address - Street 1:5000 ROCKSIDE RD STE 500
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:OH
Practice Address - Zip Code:44131-2178
Practice Address - Country:US
Practice Address - Phone:216-459-2846
Practice Address - Fax:216-901-2803
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-18
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP5551235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH13624430OtherCAQH
OH158684Medicaid