Provider Demographics
NPI:1174078638
Name:HOMITZ-DANIELS, JENNIVIERE (PMHNP-BC)
Entity type:Individual
Prefix:MRS
First Name:JENNIVIERE
Middle Name:
Last Name:HOMITZ-DANIELS
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8701 MENTOR AVE
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-6103
Mailing Address - Country:US
Mailing Address - Phone:440-266-0770
Mailing Address - Fax:440-266-0257
Practice Address - Street 1:8701 MENTOR AVE
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-6103
Practice Address - Country:US
Practice Address - Phone:440-266-0770
Practice Address - Fax:440-266-0257
Is Sole Proprietor?:No
Enumeration Date:2016-08-24
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH393799363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH366768Medicaid