Healthcare Provider Details

I. General information

NPI: 1821302654
Provider Name (Legal Business Name): PBJ CONNECTIONS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2010
Last Update Date: 10/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9734 JUG ST NW
PATASKALA OH
43062-9746
US

IV. Provider business mailing address

9734 JUG ST NW
PATASKALA OH
43062-8691
US

V. Phone/Fax

Practice location:
  • Phone: 614-395-1395
  • Fax: 740-924-2002
Mailing address:
  • Phone: 614-395-1395
  • Fax: 740-924-2002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberI.1500521
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberI.0009210
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberE0003696
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI1000061
License Number StateOH

VIII. Authorized Official

Name: MRS. HOLLY E JEDLICKA
Title or Position: PROGRAM DIRECTOR/THERAPIST
Credential: LISW-S
Phone: 614-395-1395