Provider Demographics
NPI:1114441904
Name:PYCRAFT, JEANETTE INEZ (LISW)
Entity Type:Individual
Prefix:MRS
First Name:JEANETTE
Middle Name:INEZ
Last Name:PYCRAFT
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:JEANNETTE
Other - Middle Name:INEZ
Other - Last Name:STALLINGS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LISW
Mailing Address - Street 1:329 FINDLEY AVE
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:44090-9318
Mailing Address - Country:US
Mailing Address - Phone:440-371-1572
Mailing Address - Fax:
Practice Address - Street 1:246 NORTHLAND DR STE 200A
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-3440
Practice Address - Country:US
Practice Address - Phone:330-725-9195
Practice Address - Fax:330-725-9187
Is Sole Proprietor?:No
Enumeration Date:2017-08-02
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.1700435104100000X
I.17004351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0238729Medicaid