=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629563226
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER LYNN POLING LISW, LICDC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2018
-----------------------------------------------------
Last Update Date | 07/31/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 45875 BELL SCHOOL RD STE B
-----------------------------------------------------
City | EAST LIVERPOOL
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43920-8728
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-397-6007
-----------------------------------------------------
Fax | 234-254-5655
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 45 N CANFIELD NILES RD
-----------------------------------------------------
City | AUSTINTOWN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44515-2343
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-330-8777
-----------------------------------------------------
Fax | 330-330-8555
-----------------------------------------------------
=====================================================
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 | I.2405091
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | LICDC.162101
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------