Healthcare Provider Details

I. General information

NPI: 1366844037
Provider Name (Legal Business Name): JENNA BICA SSP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JENNA SHAFFER SSP

II. Dates (important events)

Enumeration Date: 09/24/2014
Last Update Date: 09/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1135 N WEST ST
LIMA OH
45801-3655
US

IV. Provider business mailing address

1135 N WEST ST
LIMA OH
45801-3655
US

V. Phone/Fax

Practice location:
  • Phone: 419-996-3402
  • Fax:
Mailing address:
  • Phone: 419-996-3402
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberOH3150500
License Number StateOH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: