Healthcare Provider Details

I. General information

NPI: 1578665766
Provider Name (Legal Business Name): JAY ASBURY FRY LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7100 GRAPHICS WAY STE 3100
LEWIS CENTER OH
43035-0238
US

IV. Provider business mailing address

447 GLENSIDE LN
POWELL OH
43065-9485
US

V. Phone/Fax

Practice location:
  • Phone: 740-428-0428
  • Fax: 740-909-4077
Mailing address:
  • Phone: 740-549-0145
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberI-0007081
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: