MEDICARE: DR. JODIE LYNN SKILLICORN D.O.

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	2084P0800X	Psychiatry Physician	34008924	OH

General Provider Information

NPI Number	:	1922298843
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JODIE LYNN SKILLICORN D.O.

Provider Business Mailing Address
First Line	:	3610 WEST MARKET STREET
Second Line	:	SUITE 102
City	:	FAIRLAWN
State	:	OH
Zip	:	44333-9301
Country	:	US
Telephone Number	:	330-715-9282
Fax Number	:	330-752-2541

Provider Business Practice Location Address
First Line	:	3610 WEST MARKET STREET
Second Line	:
City	:	FAIRLAWN
State	:	OH
Zip	:	44333-9301
Country	:	US
Telephone Number	:	330-715-9282
Fax Number	:	330-752-2541

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

Provider Enumeration Date	:	07/26/2007
Last Update Date	:	10/27/2011

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