Healthcare Provider Details

I. General information

NPI: 1578828984
Provider Name (Legal Business Name): JENNIFER MARIE FACKELMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2012
Last Update Date: 04/24/2020
Certification Date: 04/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1822 CHERRY ST
TOLEDO OH
43608-2801
US

IV. Provider business mailing address

2283 ASHLAND AVE
TOLEDO OH
43620-1205
US

V. Phone/Fax

Practice location:
  • Phone: 419-720-9247
  • Fax:
Mailing address:
  • Phone: 419-244-2175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberS.0901179
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: