Provider Demographics
NPI:1558450833
Name:FARLEY, JENNIFER L (PSYD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:FARLEY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4075 OLD WESTERN ROW RD
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-3104
Mailing Address - Country:US
Mailing Address - Phone:513-536-0600
Mailing Address - Fax:513-536-0619
Practice Address - Street 1:4075 OLD WESTERN ROW RD
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-3104
Practice Address - Country:US
Practice Address - Phone:513-536-0600
Practice Address - Fax:513-536-0619
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5981103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q03725Medicare UPIN
OHBCCP29611Medicare PIN
OHBCCP29612Medicare PIN