Provider Demographics
NPI:1457903270
Name:STATCZAR, JENNIE (MA, LPC)
Entity Type:Individual
Prefix:
First Name:JENNIE
Middle Name:
Last Name:STATCZAR
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1170 OLD HENDERSON RD STE 100
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43220-3623
Mailing Address - Country:US
Mailing Address - Phone:614-442-7650
Mailing Address - Fax:614-442-7656
Practice Address - Street 1:1170 OLD HENDERSON RD STE 100
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43220-3623
Practice Address - Country:US
Practice Address - Phone:614-442-7650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-11
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.1801397-TRNE390200000X
OHC.2002647101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1473276Medicaid