Basic Information
| Provider Information | |||||||||
| NPI: | 1104305119 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LADRACH | ||||||||
| FirstName: | JORDAN | ||||||||
| MiddleName: | RAE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3154 HENDERSON SCHOOL RD NE | ||||||||
| Address2: | |||||||||
| City: | NEW PHILADELPHIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446638049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3309368798 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 919 2ND ST NE | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447041132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304547917 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2018 | ||||||||
| LastUpdateDate: | 09/28/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.