MEDICARE: JENNIFER L MALOTT MSW, LSCW

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	104100000X	Social Worker	33005516A	IN
2	1041C0700X	Clinical Social Worker	34006055A	IN

General Provider Information

NPI Number	:	1770722878
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER L MALOTT MSW, LSCW

Provider Business Mailing Address
First Line	:	2020 E WASHINGTON BLVD
Second Line	:	SUITE 700
City	:	FORT WAYNE
State	:	IN
Zip	:	46803-1359
Country	:	US
Telephone Number	:	260-422-3034
Fax Number	:

Provider Business Practice Location Address
First Line	:	2020 E WASHINGTON BLVD
Second Line	:	SUITE 700
City	:	FORT WAYNE
State	:	IN
Zip	:	46803-1359
Country	:	US
Telephone Number	:	260-422-3034
Fax Number	:

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

Provider Enumeration Date	:	02/12/2009
Last Update Date	:	09/30/2010

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