MEDICARE: MR. JEFFREY WALTER BENNER LISW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	I9160	OH

General Provider Information

NPI Number	:	1295745404
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JEFFREY WALTER BENNER LISW

Provider Business Mailing Address
First Line	:	1189 TOWNSHIP ROAD 346
Second Line	:
City	:	NOVA
State	:	OH
Zip	:	44859-9746
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1456 PARK AVE W
Second Line	:
City	:	MANSFIELD
State	:	OH
Zip	:	44906-2700
Country	:	US
Telephone Number	:	419-529-4602
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/09/2006
Last Update Date	:	07/08/2007

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