MEDICARE: ELYSHUA RENEE JACKSON LISW

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.2405083	OH

General Provider Information

NPI Number	:	1477306454
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELYSHUA RENEE JACKSON LISW

Provider Business Mailing Address
First Line	:	3053 E HUDSON ST
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43219-1632
Country	:	US
Telephone Number	:	614-537-2240
Fax Number	:

Provider Business Practice Location Address
First Line	:	1550 OLD HENDERSON RD STE N-271
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43220-3626
Country	:	US
Telephone Number	:	614-456-7334
Fax Number	:

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

Provider Enumeration Date	:	04/09/2024
Last Update Date	:	01/02/2025

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