Provider Demographics
NPI:1164894754
Name:ROGERS, JESSICA E (LISW-S)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:E
Last Name:ROGERS
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1251 W BROAD ST STE 105
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43222-1359
Mailing Address - Country:US
Mailing Address - Phone:614-212-4724
Mailing Address - Fax:
Practice Address - Street 1:1251 W BROAD ST STE 105
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43222-1359
Practice Address - Country:US
Practice Address - Phone:614-212-4724
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-22
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.20022081041C0700X, 1041C0700X
OHS.1600449104100000X, 104100000X
OH390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2846675Medicaid