Provider Demographics
NPI:1396331740
Name:FARMER, MARY JENNIFER
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JENNIFER
Last Name:FARMER
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 1:168 RAVINE RIDGE DR S
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:OH
Mailing Address - Zip Code:43065-9321
Mailing Address - Country:US
Mailing Address - Phone:740-417-6849
Mailing Address - Fax:
Practice Address - Street 1:168 RAVINE RIDGE DR S
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:OH
Practice Address - Zip Code:43065-9321
Practice Address - Country:US
Practice Address - Phone:740-417-6849
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-18
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2107826251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services