Healthcare Provider Details

I. General information

NPI: 1417401316
Provider Name (Legal Business Name): JESSICA LAVELLE LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2016
Last Update Date: 08/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1479 COLLINS AVE
MARYSVILLE OH
43040-8808
US

IV. Provider business mailing address

35 LOTSPEICH AVE
LONDON OH
43140-1230
US

V. Phone/Fax

Practice location:
  • Phone: 937-642-1065
  • Fax:
Mailing address:
  • Phone: 216-513-6019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.1600119
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: