MEDICARE: JESSICA NICOLE ARCHER 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.2103129	OH

General Provider Information

NPI Number	:	1669963245
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA NICOLE ARCHER LISW-S

Provider Business Mailing Address
First Line	:	824 E BROAD ST
Second Line	:
City	:	ELYRIA
State	:	OH
Zip	:	44035-6559
Country	:	US
Telephone Number	:	440-477-7195
Fax Number	:

Provider Business Practice Location Address
First Line	:	824 E BROAD ST
Second Line	:
City	:	ELYRIA
State	:	OH
Zip	:	44035-6559
Country	:	US
Telephone Number	:	440-477-7195
Fax Number	:

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

Provider Enumeration Date	:	05/19/2018
Last Update Date	:	04/08/2026

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