Healthcare Provider Details

I. General information

NPI: 1245658830
Provider Name (Legal Business Name): JEFFERY BANKS LICDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2014
Last Update Date: 01/22/2025
Certification Date: 01/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 EZZARD CHARLES DR
CINCINNATI OH
45214-2525
US

IV. Provider business mailing address

1121 SPRINGWATER CT
CINCINNATI OH
45215-1164
US

V. Phone/Fax

Practice location:
  • Phone: 513-381-6672
  • Fax:
Mailing address:
  • Phone: 513-578-1699
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number121032
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLICDC162151
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: