Healthcare Provider Details

I. General information

NPI: 1639657943
Provider Name (Legal Business Name): JENNIFER BETH WYSE LISW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2018
Last Update Date: 05/14/2021
Certification Date: 05/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10524 EUCLID AVE
CLEVELAND OH
44106-2205
US

IV. Provider business mailing address

10524 EUCLID AVE
CLEVELAND OH
44106-2205
US

V. Phone/Fax

Practice location:
  • Phone: 216-844-2400
  • Fax:
Mailing address:
  • Phone: 216-844-2400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number088515
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.2102692
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: