Provider Demographics
NPI:1235233966
Name:PELTON, JEANETTE M (LISW-S)
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:M
Last Name:PELTON
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 1:217 E CHESTNUT ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:OH
Mailing Address - Zip Code:43050-3466
Mailing Address - Country:US
Mailing Address - Phone:740-392-3111
Mailing Address - Fax:740-392-3182
Practice Address - Street 1:217 E CHESTNUT ST UNIT A
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050-3466
Practice Address - Country:US
Practice Address - Phone:740-392-3111
Practice Address - Fax:740-392-3182
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-12
Last Update Date:2012-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI00097701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPESW35211Medicare UPIN