MEDICARE: JAMILA EBONY PROVITT LSW, BA, MSW

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
2	104100000X	Social Worker	S.1904129	OH

General Provider Information

NPI Number	:	1700366614
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMILA EBONY PROVITT LSW, BA, MSW

Provider Business Mailing Address
First Line	:	8261 MARKET ST
Second Line	:
City	:	BOARDMAN
State	:	OH
Zip	:	44512-6254
Country	:	US
Telephone Number	:	330-286-0050
Fax Number	:	330-286-0055

Provider Business Practice Location Address
First Line	:	2671 YOUNGSTOWN RD SE
Second Line	:
City	:	WARREN
State	:	OH
Zip	:	44484-4404
Country	:	US
Telephone Number	:	330-469-9743
Fax Number	:	330-286-0055

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

Provider Enumeration Date	:	08/20/2018
Last Update Date	:	02/20/2020

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