Provider Demographics
NPI:1982194510
Name:KOONS-WESTON, JENNIFER L (LSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:KOONS-WESTON
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 1:434 EASTLAND RD
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:OH
Mailing Address - Zip Code:44017-1217
Mailing Address - Country:US
Mailing Address - Phone:740-216-9067
Mailing Address - Fax:
Practice Address - Street 1:1592 GRANVILLE PIKE
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130-1076
Practice Address - Country:US
Practice Address - Phone:740-687-0835
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-18
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1802064104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1982194510Medicaid