Healthcare Provider Details

I. General information

NPI: 1083176168
Provider Name (Legal Business Name): JARED TIMBERLAKE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2019
Last Update Date: 04/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4578 GALLIA PIKE
FRANKLIN FURNACE OH
45629-8600
US

IV. Provider business mailing address

923 FINDLAY ST
PORTSMOUTH OH
45662-4148
US

V. Phone/Fax

Practice location:
  • Phone: 740-351-0008
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberQMHS
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberCMS
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: