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General NPI Number Information
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NPI Number | 1639269897
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Entity Type | Individual
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Provider Name | JENNIFER ROSE BANAK LCSW
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Gender | Female
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Dates
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Enumeration Date | 10/16/2006
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Last Update Date | 04/07/2023
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Provider Practice Location Address
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Address Line | 135 E 38TH ST
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City | ERIE
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State | PA
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Zip | 16504-1559
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Country | US
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Telephone | 814-860-2639
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Fax |
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Provider Business Mailing Address
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Address Line | 1326 ROBIN RD S
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City | ST PETERSBURG
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State | FL
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Zip | 33707-3829
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Country | US
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Telephone | 740-993-9246
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | I.1440290-SUPV
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | CW015449
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License Number State | PA
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