Healthcare Provider Details

I. General information

NPI: 1083542161
Provider Name (Legal Business Name): JONATHAN WELLS LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2026
Last Update Date: 05/11/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

367 E BROAD ST APT 606
COLUMBUS OH
43215-3990
US

IV. Provider business mailing address

PO BOX 15044
COLUMBUS OH
43215-0044
US

V. Phone/Fax

Practice location:
  • Phone: 606-585-2531
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.2203504
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: