MEDICARE: MRS. JENISE MARY ANN HARMON 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	104100000X	Social Worker	S31926	OH
2	1041C0700X	Clinical Social Worker	I.1101322	OH

General Provider Information

NPI Number	:	1912216672
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JENISE MARY ANN HARMON LISW

Provider Business Mailing Address
First Line	:	3474 N HIGH ST
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43214-4056
Country	:	US
Telephone Number	:	614-500-3679
Fax Number	:

Provider Business Practice Location Address
First Line	:	3474 N HIGH ST
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43214-4056
Country	:	US
Telephone Number	:	614-500-3679
Fax Number	:

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

Provider Enumeration Date	:	09/29/2010
Last Update Date	:	11/01/2011

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