Provider Demographics
NPI:1518155159
Name:JENNINGS, MYLO G (MSW, PHD, LISW-S)
Entity Type:Individual
Prefix:DR
First Name:MYLO
Middle Name:G
Last Name:JENNINGS
Suffix:
Gender:M
Credentials:MSW, PHD, LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2397 N TOUSSAINT PORTAGE RD
Mailing Address - Street 2:
Mailing Address - City:OAK HARBOR
Mailing Address - State:OH
Mailing Address - Zip Code:43449-9465
Mailing Address - Country:US
Mailing Address - Phone:419-898-9915
Mailing Address - Fax:
Practice Address - Street 1:2397 N TOUSSAINT PORTAGE RD
Practice Address - Street 2:
Practice Address - City:OAK HARBOR
Practice Address - State:OH
Practice Address - Zip Code:43449-9465
Practice Address - Country:US
Practice Address - Phone:419-898-9615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-09
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI00086331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical