Provider Demographics
NPI:1033460480
Name:JEDLICKA, HOLLY (MSW, LISW-S)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:JEDLICKA
Suffix:
Gender:F
Credentials:MSW, LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 92
Mailing Address - Street 2:
Mailing Address - City:KIRKERSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43033-0092
Mailing Address - Country:US
Mailing Address - Phone:614-395-1395
Mailing Address - Fax:740-927-1516
Practice Address - Street 1:9800 JUG ST NW
Practice Address - Street 2:
Practice Address - City:PATASKALA
Practice Address - State:OH
Practice Address - Zip Code:43062-8691
Practice Address - Country:US
Practice Address - Phone:614-395-1395
Practice Address - Fax:740-927-1516
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-25
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH10000611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical