Provider Demographics
NPI:1962682872
Name:SHADIK, JENNIFER A (LISW-SUPV)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:SHADIK
Suffix:
Gender:F
Credentials:LISW-SUPV
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:CLISSOLD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 188
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-0188
Mailing Address - Country:US
Mailing Address - Phone:740-773-4366
Mailing Address - Fax:
Practice Address - Street 1:9 KENNY DR
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701-9406
Practice Address - Country:US
Practice Address - Phone:740-773-4366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-08
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.1700236-SUPV104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker