=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235625419
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JERITA TARELLE WILLIAMS LSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2018
-----------------------------------------------------
Last Update Date | 07/10/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3964 HAMILTON SQUARE BLVD
-----------------------------------------------------
City | GROVEPORT
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43125-9119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 234-542-9457
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3942 CLEGGAN ST
-----------------------------------------------------
City | CANAL WINCHESTER
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43110-8125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 234-542-9457
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | S.0900544
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------