=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891153755
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA PUCKETT LSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/08/2016
-----------------------------------------------------
Last Update Date | 02/08/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 149 CHILLICOTHE AVE
-----------------------------------------------------
City | HILLSBORO
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45133-1533
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-393-9662
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 104 ERIN CT PO BOX 823
-----------------------------------------------------
City | HILLSBORO
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45133-8591
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-393-4562
-----------------------------------------------------
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 | S1502547
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------