Provider Demographics
NPI:1891219150
Name:WLODARCZYK, JENNIFER (LCDC III)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:WLODARCZYK
Suffix:
Gender:F
Credentials:LCDC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 ALBERT SABIN WAY
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45229-2838
Mailing Address - Country:US
Mailing Address - Phone:513-887-4309
Mailing Address - Fax:
Practice Address - Street 1:2250 PLEASANT AVE
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:OH
Practice Address - Zip Code:45015-1135
Practice Address - Country:US
Practice Address - Phone:513-868-1562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-28
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLCDCIII.001119101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0466859Medicaid