Provider Demographics
NPI:1023676186
Name:MINIC, JERAD (LSW)
Entity type:Individual
Prefix:
First Name:JERAD
Middle Name:
Last Name:MINIC
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:796 MANCHESTER CT
Mailing Address - Street 2:
Mailing Address - City:PICKERINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43147-2079
Mailing Address - Country:US
Mailing Address - Phone:937-441-0159
Mailing Address - Fax:
Practice Address - Street 1:195 UNION ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-3919
Practice Address - Country:US
Practice Address - Phone:740-485-8005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-04
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1903607104100000X
OHI.23046731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0352324Medicaid