Provider Demographics
NPI:1841314507
Name:ROSENBAUM, JEFFERY D (PHD)
Entity type:Individual
Prefix:DR
First Name:JEFFERY
Middle Name:D
Last Name:ROSENBAUM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23875 COMMERCE PARK RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5834
Mailing Address - Country:US
Mailing Address - Phone:216-292-7480
Mailing Address - Fax:216-292-7042
Practice Address - Street 1:23875 COMMERCE PARK RD
Practice Address - Street 2:SUITE 105
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-5834
Practice Address - Country:US
Practice Address - Phone:216-292-7480
Practice Address - Fax:216-292-7042
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2951103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH477578Medicaid
OH477578Medicaid