Healthcare Provider Details

I. General information

NPI: 1053780890
Provider Name (Legal Business Name): JEANNE LEVY LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2015
Last Update Date: 12/11/2019
Certification Date: 12/11/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1810 SULLIVANT AVE
COLUMBUS OH
43222-1055
US

IV. Provider business mailing address

1810 SULLIVANT AVE
COLUMBUS OH
43222-1055
US

V. Phone/Fax

Practice location:
  • Phone: 614-752-0333
  • Fax: 614-995-3268
Mailing address:
  • Phone: 614-752-0333
  • Fax: 614-995-3268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.1501439
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: