Provider Demographics
NPI:1093139057
Name:JEFFREY P LAND LISW-S LLC
Entity Type:Organization
Organization Name:JEFFREY P LAND LISW-S LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MBR
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:LAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-251-0237
Mailing Address - Street 1:7048 BENTLEY PL
Mailing Address - Street 2:
Mailing Address - City:PAINESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44077-2212
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6449 WILSON MILLS RD
Practice Address - Street 2:
Practice Address - City:MAYFIELD VILLAGE
Practice Address - State:OH
Practice Address - Zip Code:44143-3443
Practice Address - Country:US
Practice Address - Phone:440-442-8800
Practice Address - Fax:440-442-8804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-11
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI0001755-SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH12624773OtherCAQH