=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164039426
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANNESCO'S JOURNEY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/30/2020
-----------------------------------------------------
Last Update Date | 09/30/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 E CAMPUS VIEW BLVD STE 200
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43235-4678
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-259-8879
-----------------------------------------------------
Fax | 614-413-1537
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 E CAMPUS VIEW BLVD STE 200
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43235-4678
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-259-8879
-----------------------------------------------------
Fax | 614-413-1537
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDER & CLINICAL THERAPIST
-----------------------------------------------------
Name | NAKEIA HUDSON
-----------------------------------------------------
Credential | MBA, MSW, LISW-S
-----------------------------------------------------
Telephone | 614-259-8879
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------