Healthcare Provider Details

I. General information

NPI: 1447184809
Provider Name (Legal Business Name): JADE BANIK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2026
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 STATE ROUTE 664 N
LOGAN OH
43138-8541
US

IV. Provider business mailing address

8125 GILLS HOLLOW RD
ROSEVILLE OH
43777-9762
US

V. Phone/Fax

Practice location:
  • Phone: 740-380-8000
  • Fax:
Mailing address:
  • Phone: 740-891-8027
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number007854
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: