Provider Demographics
NPI:1013169275
Name:FORREST, JERI ANN (LCSW)
Entity Type:Individual
Prefix:
First Name:JERI
Middle Name:ANN
Last Name:FORREST
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 RIVER RUN TRL
Mailing Address - Street 2:APT. D
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-6080
Mailing Address - Country:US
Mailing Address - Phone:260-515-4575
Mailing Address - Fax:
Practice Address - Street 1:1818 CAREW ST
Practice Address - Street 2:SUITE 230
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4788
Practice Address - Country:US
Practice Address - Phone:260-373-8000
Practice Address - Fax:260-373-8003
Is Sole Proprietor?:No
Enumeration Date:2008-10-21
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34005624A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical