Provider Demographics
NPI:1770365629
Name:CALLOWAY, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:CALLOWAY
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 1:1496 S GREEN RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44121-4038
Mailing Address - Country:US
Mailing Address - Phone:216-389-7413
Mailing Address - Fax:216-916-0995
Practice Address - Street 1:1496 S GREEN RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44121-4038
Practice Address - Country:US
Practice Address - Phone:216-389-7413
Practice Address - Fax:216-916-0995
Is Sole Proprietor?:No
Enumeration Date:2023-10-16
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.186153101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)