Provider Demographics
NPI:1811577315
Name:JANSEN, MARY LEE (LSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LEE
Last Name:JANSEN
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:737 BANK ST
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:OH
Mailing Address - Zip Code:44254-1025
Mailing Address - Country:US
Mailing Address - Phone:330-636-1741
Mailing Address - Fax:330-948-0880
Practice Address - Street 1:737 BANK ST
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:OH
Practice Address - Zip Code:44254-1025
Practice Address - Country:US
Practice Address - Phone:330-636-1741
Practice Address - Fax:330-948-0880
Is Sole Proprietor?:No
Enumeration Date:2021-04-09
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.0029719104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker