Provider Demographics
NPI:1669866794
Name:JAMSHIDI, ALEXIS M
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:M
Last Name:JAMSHIDI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALEXIS
Other - Middle Name:M
Other - Last Name:POTTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:DEPT 781625
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1625
Mailing Address - Country:US
Mailing Address - Phone:614-355-8004
Mailing Address - Fax:614-355-2220
Practice Address - Street 1:399 E MAIN ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-5384
Practice Address - Country:US
Practice Address - Phone:614-355-8550
Practice Address - Fax:614-355-8593
Is Sole Proprietor?:No
Enumeration Date:2015-03-26
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI15001561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2846675Medicaid