Provider Demographics
NPI:1235625419
Name:WILLIAMS, JERITA TARELLE (LSW)
Entity Type:Individual
Prefix:
First Name:JERITA
Middle Name:TARELLE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3942 CLEGGAN ST
Mailing Address - Street 2:
Mailing Address - City:CANAL WINCHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:43110-8125
Mailing Address - Country:US
Mailing Address - Phone:234-542-9457
Mailing Address - Fax:
Practice Address - Street 1:3964 HAMILTON SQUARE BLVD
Practice Address - Street 2:
Practice Address - City:GROVEPORT
Practice Address - State:OH
Practice Address - Zip Code:43125-9119
Practice Address - Country:US
Practice Address - Phone:234-542-9457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-10
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.0900544104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty