Provider Demographics
NPI:1942803747
Name:DAMBROSIO-COOPER, JENNIFER R (INDEPENDENT PROVIDER)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:R
Last Name:DAMBROSIO-COOPER
Suffix:
Gender:F
Credentials:INDEPENDENT PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10000 FIRESTONE LN
Mailing Address - Street 2:
Mailing Address - City:MACEDONIA
Mailing Address - State:OH
Mailing Address - Zip Code:44056-1511
Mailing Address - Country:US
Mailing Address - Phone:440-227-1371
Mailing Address - Fax:
Practice Address - Street 1:10000 FIRESTONE LN
Practice Address - Street 2:
Practice Address - City:MACEDONIA
Practice Address - State:OH
Practice Address - Zip Code:44056-1511
Practice Address - Country:US
Practice Address - Phone:440-227-1371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH7710963Medicaid