Healthcare Provider Details

I. General information

NPI: 1003557851
Provider Name (Legal Business Name): JENNIFER LYNN SHORTER MSW, LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 04/05/2022
Certification Date: 04/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6150 PARK SQUARE DR
LORAIN OH
44053-4153
US

IV. Provider business mailing address

1925 HAYES AVE
SANDUSKY OH
44870-4737
US

V. Phone/Fax

Practice location:
  • Phone: 440-984-3882
  • Fax:
Mailing address:
  • Phone: 419-557-5177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberS.1700644
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: