Provider Demographics
NPI:1669050373
Name:GROOMS, JENNIFER L (CDCA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:GROOMS
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6136 W RIVER RD S
Mailing Address - Street 2:
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035-5432
Mailing Address - Country:US
Mailing Address - Phone:440-258-8452
Mailing Address - Fax:
Practice Address - Street 1:2115 W PARK DR
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-1138
Practice Address - Country:US
Practice Address - Phone:440-989-4900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-01
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLCDCII.161781101YA0400X
OHCDCA.175731101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)