Provider Demographics
NPI:1821302654
Name:PBJ CONNECTIONS, INC.
Entity Type:Organization
Organization Name:PBJ CONNECTIONS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR/THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:E
Authorized Official - Last Name:JEDLICKA
Authorized Official - Suffix:
Authorized Official - Credentials:LISW-S
Authorized Official - Phone:614-395-1395
Mailing Address - Street 1:9734 JUG ST NW
Mailing Address - Street 2:
Mailing Address - City:PATASKALA
Mailing Address - State:OH
Mailing Address - Zip Code:43062-8691
Mailing Address - Country:US
Mailing Address - Phone:614-395-1395
Mailing Address - Fax:740-924-2002
Practice Address - Street 1:9734 JUG ST NW
Practice Address - Street 2:
Practice Address - City:PATASKALA
Practice Address - State:OH
Practice Address - Zip Code:43062-9746
Practice Address - Country:US
Practice Address - Phone:614-395-1395
Practice Address - Fax:740-924-2002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-04
Last Update Date:2016-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.1500521101YM0800X
OHI.0009210101YM0800X
OHE0003696101YP2500X
OHI10000611041C0700X
OHC1300444101YP2500X
OHI11013491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2807341Medicaid