Healthcare Provider Details

I. General information

NPI: 1912856477
Provider Name (Legal Business Name): JACQUELINE M FANNING
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2026
Last Update Date: 01/27/2026
Certification Date: 01/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1490 E MAIN ST
COLUMBUS OH
43205-2140
US

IV. Provider business mailing address

1490 E MAIN ST
COLUMBUS OH
43205-2140
US

V. Phone/Fax

Practice location:
  • Phone: 614-252-0731
  • Fax: 624-252-8468
Mailing address:
  • Phone: 614-252-0731
  • Fax: 624-252-8468

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.2504702-TRNE
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: