Provider Demographics
NPI:1427650613
Name:DANIELSKI, JEROMY (CDCA)
Entity type:Individual
Prefix:
First Name:JEROMY
Middle Name:
Last Name:DANIELSKI
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2438 W. STATE ST
Mailing Address - Street 2:OLD ORCHARD MOTEL
Mailing Address - City:FREMONT
Mailing Address - State:OH
Mailing Address - Zip Code:43420
Mailing Address - Country:US
Mailing Address - Phone:419-455-5533
Mailing Address - Fax:
Practice Address - Street 1:825 JUNE ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:OH
Practice Address - Zip Code:43420-3417
Practice Address - Country:US
Practice Address - Phone:419-455-5533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-12
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.174935101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)