=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023505872
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA L LUTTRELL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/17/2018
-----------------------------------------------------
Last Update Date | 04/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 780 PARK AVE W
-----------------------------------------------------
City | MANSFIELD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44906-3009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-709-8103
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 47 SUNSET RD N
-----------------------------------------------------
City | ONTARIO
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44906-2273
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-354-1614
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | CDCA.151810
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------