=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740695543
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEFFREY WHEELBARGER L.I.C.D.C. - C.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/01/2014
-----------------------------------------------------
Last Update Date | 07/01/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1851 STATE ROUTE 56
-----------------------------------------------------
City | LONDON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43140-0740
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-852-9777
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10285 TUSCANY DR
-----------------------------------------------------
City | PLAIN CITY
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43064-7009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-504-5382
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 981295
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------