MEDICARE: JO ELLEN LAYNE LISW-S

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	I 0008834	OH

General Provider Information

NPI Number	:	1114227311
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JO ELLEN LAYNE LISW-S

Provider Business Mailing Address
First Line	:	2219 ACORN DR
Second Line	:
City	:	KETTERING
State	:	OH
Zip	:	45419-2745
Country	:	US
Telephone Number	:	937-760-0268
Fax Number	:

Provider Business Practice Location Address
First Line	:	2219 ACORN DR
Second Line	:
City	:	KETTERING
State	:	OH
Zip	:	45419-2745
Country	:	US
Telephone Number	:	937-898-6268
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/22/2010
Last Update Date	:	10/22/2010

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