Healthcare Provider Details

I. General information

NPI: 1235674763
Provider Name (Legal Business Name): JESSICA OBRIEN LCDC III
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2016
Last Update Date: 07/26/2022
Certification Date: 07/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3768 E MAIN ST
WHITEHALL OH
43213-2925
US

IV. Provider business mailing address

615 ELSINORE PL STE 200
CINCINNATI OH
45202-1457
US

V. Phone/Fax

Practice location:
  • Phone: 513-834-7063
  • Fax:
Mailing address:
  • Phone: 513-834-7063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCDCIII.161071
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: