Provider Demographics
NPI:1891831640
Name:BOUTWELL, JANE E (LSW,LPCC)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:E
Last Name:BOUTWELL
Suffix:
Gender:F
Credentials:LSW,LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 S COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44410-1305
Mailing Address - Country:US
Mailing Address - Phone:330-395-9563
Mailing Address - Fax:
Practice Address - Street 1:318 MAHONING AVE NW
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44483-4605
Practice Address - Country:US
Practice Address - Phone:330-395-9563
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE 0002188101YM0800X
OHS 0006115104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker