Provider Demographics
NPI:1760958607
Name:JOSEPH, JENNIFER (LISW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:JOSEPH
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7519 MENTOR AVE STE 114
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-5410
Mailing Address - Country:US
Mailing Address - Phone:440-701-6170
Mailing Address - Fax:440-527-8043
Practice Address - Street 1:7519 MENTOR AVE STE 114
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-5410
Practice Address - Country:US
Practice Address - Phone:440-701-6170
Practice Address - Fax:440-527-8043
Is Sole Proprietor?:No
Enumeration Date:2018-10-18
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.23044941041C0700X
OHS.2004854104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0320640Medicaid