Provider Demographics
NPI:1255998209
Name:SIMS, JOLISA R
Entity type:Individual
Prefix:
First Name:JOLISA
Middle Name:R
Last Name:SIMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:467 SANDERSON AVE
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:OH
Mailing Address - Zip Code:44405-1464
Mailing Address - Country:US
Mailing Address - Phone:330-406-7171
Mailing Address - Fax:
Practice Address - Street 1:467 SANDERSON AVE
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:OH
Practice Address - Zip Code:44405-1464
Practice Address - Country:US
Practice Address - Phone:330-406-7171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-24
Last Update Date:2024-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OHCDCA.164953101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)