Healthcare Provider Details

I. General information

NPI: 1962812453
Provider Name (Legal Business Name): JESSICA MARTIN LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2014
Last Update Date: 05/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

658 W MARKET ST
LIMA OH
45801-4653
US

IV. Provider business mailing address

658 W MARKET ST
LIMA OH
45801-4653
US

V. Phone/Fax

Practice location:
  • Phone: 419-222-1527
  • Fax: 419-222-3586
Mailing address:
  • Phone: 419-222-1527
  • Fax: 419-222-3586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberS.0500355
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: