Provider Demographics
NPI:1811367014
Name:GREATHOUSE, JESSICA RENE (LISW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:RENE
Last Name:GREATHOUSE
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 1:1490 WHEATLAND AVE
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-4940
Mailing Address - Country:US
Mailing Address - Phone:937-264-0084
Mailing Address - Fax:937-264-0095
Practice Address - Street 1:1785 BIG HILL RD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45439-2219
Practice Address - Country:US
Practice Address - Phone:937-830-5313
Practice Address - Fax:937-264-0095
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-30
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI 150004431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical