Healthcare Provider Details

I. General information

NPI: 1770252397
Provider Name (Legal Business Name): TYLER JACKSON LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2021
Last Update Date: 06/15/2022
Certification Date: 06/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 W BROAD ST STE 200
COLUMBUS OH
43222-1478
US

IV. Provider business mailing address

815 W BROAD ST STE 200
COLUMBUS OH
43222-1478
US

V. Phone/Fax

Practice location:
  • Phone: 614-717-0822
  • Fax:
Mailing address:
  • Phone: 614-717-0822
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number2101853
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: