MEDICARE: JENNIFER WALSH L.I.S.W.

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	I5601	OH

General Provider Information

NPI Number	:	1720117948
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER WALSH L.I.S.W.

Provider Business Mailing Address
First Line	:	2049 LAKE AVE
Second Line	:	SPOSITO BUILDING
City	:	ASHTABULA
State	:	OH
Zip	:	44004-3433
Country	:	US
Telephone Number	:	440-992-0274
Fax Number	:

Provider Business Practice Location Address
First Line	:	2049 LAKE AVE
Second Line	:	SPOSITO BUILDING
City	:	ASHTABULA
State	:	OH
Zip	:	44004-3433
Country	:	US
Telephone Number	:	440-992-0274
Fax Number	:

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

Provider Enumeration Date	:	03/05/2007
Last Update Date	:	07/08/2007

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