NPIMap

Organization Active NPI

Jordan Community Residential Center

  • Addiction (Substance Use Disorder) Psychologist
  • Willoughby, OH
National Provider Identifier
1164068524
Registry record updated Feb 4, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Addiction (Substance Use Disorder) PsychologistTaxonomy code 103TA0400X
Legal business name
JORDAN COMMUNITY RESIDENTIAL CENTER
Practice address
30841 Euclid Ave Ste 103
Willoughby, OH 44094-3100
Phone
(216) 441-2496
Fax
(216) 634-9611
NPI assigned
Nov 20, 2019
Last updated
Feb 4, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 4, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Ms. Tenisha GantNPI 1073136594
Title
Chief Executive Officer
Phone
(216) 441-2496

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Addiction (Substance Use Disorder) PsychologistGroup: 193200000X MULTI-SPECIALTY GROUP 103TA0400X Primary

Addresses

Primary practice location

30841 Euclid Ave Ste 103
Willoughby, OH 44094-3100

Mailing address

30841 Euclid Ave Ste 103
Willoughby, OH 44094-3100
Phone (216) 441-2496

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OH

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20230316000356 OH Part B Supplier - Clinic/Group Practice 6305210220 Receives reassigned benefits from 1 practitioner
Practice locations: Willoughby, OH

National Provider Directory

National Provider Directory
Tax ID family
Jordan Community Residential2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Practitioners & affiliated clinicians

Practitioners 16

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 16

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1574208000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1738627200000",
    "number": "1164068524",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "30841 EUCLID AVE STE 103",
            "city": "WILLOUGHBY",
            "state": "OH",
            "postal_code": "440943100",
            "telephone_number": "216-441-2496",
            "fax_number": "216-634-9611"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "30841 EUCLID AVE STE 103",
            "city": "WILLOUGHBY",
            "state": "OH",
            "postal_code": "440943100",
            "telephone_number": "216-441-2496",
            "fax_number": "216-634-9611"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "JORDAN COMMUNITY RESIDENTIAL CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-11-20",
        "last_updated": "2025-02-04",
        "certification_date": "2025-02-04",
        "status": "A",
        "authorized_official_last_name": "GANT",
        "authorized_official_first_name": "TENISHA",
        "authorized_official_title_or_position": "CHIEF EXECUTIVE OFFICER",
        "authorized_official_telephone_number": "216-441-2496",
        "authorized_official_name_prefix": "Ms."
    },
    "taxonomies": [
        {
            "code": "103TA0400X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychologist, Addiction (Substance Use Disorder)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Willoughby, OH

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 4, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.