Healthcare Provider Details

I. General information

NPI: 1295764322
Provider Name (Legal Business Name): JEAN MARIE TIDD LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 SPRUCE ST
COLUMBUS OH
43215-2204
US

IV. Provider business mailing address

548 TIBET RD
COLUMBUS OH
43202-2249
US

V. Phone/Fax

Practice location:
  • Phone: 614-227-6865
  • Fax: 614-227-6873
Mailing address:
  • Phone: 614-263-5594
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-8292
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: