=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386079150
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA LOAR MSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2013
-----------------------------------------------------
Last Update Date | 09/11/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18 CLINIC DR
-----------------------------------------------------
City | PARIS
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40361-2161
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-987-6810
-----------------------------------------------------
Fax | 859-987-6812
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18 CLINIC DR
-----------------------------------------------------
City | PARIS
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40361-2161
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-987-6810
-----------------------------------------------------
Fax | 859-987-6812
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 6176
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------