Provider Demographics
NPI:1700366614
Name:PROVITT, JAMILA EBONY (LSW, BA, MSW)
Entity Type:Individual
Prefix:
First Name:JAMILA
Middle Name:EBONY
Last Name:PROVITT
Suffix:
Gender:F
Credentials:LSW, BA, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8261 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-6254
Mailing Address - Country:US
Mailing Address - Phone:330-286-0050
Mailing Address - Fax:330-286-0055
Practice Address - Street 1:2671 YOUNGSTOWN RD SE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484-4404
Practice Address - Country:US
Practice Address - Phone:330-469-9743
Practice Address - Fax:330-286-0055
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-20
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X, 1041C0700X
OHS.1904129104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical