Healthcare Provider Details

I. General information

NPI: 1932980125
Provider Name (Legal Business Name): JESSICA MARIE DAVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2023
Last Update Date: 10/12/2023
Certification Date: 10/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 WESTERN AVE
CHILLICOTHEE OH
45601-2343
US

IV. Provider business mailing address

4304 OLD SCIOTO TRL
PORTSMOUTH OH
45662-6672
US

V. Phone/Fax

Practice location:
  • Phone: 740-351-9298
  • Fax: 740-529-0553
Mailing address:
  • Phone: 743-519-2989
  • Fax: 740-529-0553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.185048
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: