Basic Information
| Provider Information | |||||||||
| NPI: | 1487890109 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROGERS | ||||||||
| FirstName: | JERILYN | ||||||||
| MiddleName: | DENISE | ||||||||
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| Credential: | LCDCIII | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24200 CHAGRIN BLVD | ||||||||
| Address2: | |||||||||
| City: | BEACHWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441225550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2168316466 | ||||||||
| FaxNumber: | 2167666084 | ||||||||
| Practice Location | |||||||||
| Address1: | 24200 CHAGRIN BLVD | ||||||||
| Address2: | |||||||||
| City: | BEACHWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441225550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2168316466 | ||||||||
| FaxNumber: | 2167666084 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2008 | ||||||||
| LastUpdateDate: | 12/30/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 031105 | OH | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | C0600270 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.