Basic Information
Provider Information
NPI: 1154820082
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: CORWIN
FirstName: JENNIFER
MiddleName: LYNN
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 2140 W 38TH ST APT 1
Address2:  
City: CLEVELAND
State: OH
PostalCode: 441133861
CountryCode: US
TelephoneNumber: 2169375661
FaxNumber:  
Practice Location
Address1: 3518 W 25TH ST
Address2:  
City: CLEVELAND
State: OH
PostalCode: 441091951
CountryCode: US
TelephoneNumber: 2167412241
FaxNumber:  
Other Information
ProviderEnumerationDate: 02/06/2018
LastUpdateDate: 02/06/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
106S00000X  Y    

No ID Information.


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