MEDICARE: JOSEPH GERARD JARDINE 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	6801065763	MI
2	1041C0700X	Clinical Social Worker	I.0004783-SUPV	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	I.4783	OTHER	OH	MY OHIO SOCIAL WORK LICENSE
2	6801065763	OTHER	MI	MICHIGAN SOCIAL WORK LICENSE

General Provider Information

NPI Number	:	1578033098
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSEPH GERARD JARDINE LISW

Provider Business Mailing Address
First Line	:	5855 MONROE ST STE 201
Second Line	:
City	:	SYLVANIA
State	:	OH
Zip	:	43560-2270
Country	:	US
Telephone Number	:	419-291-1801
Fax Number	:

Provider Business Practice Location Address
First Line	:	1806 MADISON AVE
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43604-5460
Country	:	US
Telephone Number	:	419-291-1801
Fax Number	:

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

Provider Enumeration Date	:	11/27/2018
Last Update Date	:	08/15/2019

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