Provider Demographics
NPI:1447737846
Name:ANAHATA, JENNIFER (LISW, LICDC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:ANAHATA
Suffix:
Gender:F
Credentials:LISW, LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4832 WENDLER BLVD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43230-1645
Mailing Address - Country:US
Mailing Address - Phone:340-643-7758
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:614-610-1506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-27
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLICDC.162098101YA0400X
OHI.21031551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)