Provider Demographics
NPI:1306486691
Name:CHICWAK, JODI R
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:R
Last Name:CHICWAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JODI
Other - Middle Name:R
Other - Last Name:PHILLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:841 STEUBENVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:OH
Mailing Address - Zip Code:43725-2301
Mailing Address - Country:US
Mailing Address - Phone:855-962-7247
Mailing Address - Fax:855-692-7247
Practice Address - Street 1:841 STEUBENVILLE AVE
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:OH
Practice Address - Zip Code:43725-2301
Practice Address - Country:US
Practice Address - Phone:855-962-7247
Practice Address - Fax:855-692-7247
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-14
Last Update Date:2025-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OHCDA.18009171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0038492Medicaid