Provider Demographics
NPI:1417653502
Name:DEWALT, JESTINA
Entity Type:Individual
Prefix:
First Name:JESTINA
Middle Name:
Last Name:DEWALT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 E DUBLIN GRANVILLE RD
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43085-3192
Mailing Address - Country:US
Mailing Address - Phone:614-837-3800
Mailing Address - Fax:
Practice Address - Street 1:2438 KIMBERLY WOODS DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43232-4290
Practice Address - Country:US
Practice Address - Phone:614-837-3800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-01
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2615030Medicaid