Healthcare Provider Details

I. General information

NPI: 1336647049
Provider Name (Legal Business Name): JODI LYNN WITT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JODI LYNN WITT

II. Dates (important events)

Enumeration Date: 01/28/2018
Last Update Date: 01/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

153 DUANE ST
CLYDE OH
43410-1611
US

IV. Provider business mailing address

153 DUANE ST
CLYDE OH
43410-1611
US

V. Phone/Fax

Practice location:
  • Phone: 419-603-8516
  • Fax:
Mailing address:
  • Phone: 419-603-8516
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number337561
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: