Provider Demographics
NPI:1700442191
Name:GIFFEN, JERALYN NICOLE (MSW,LSW)
Entity Type:Individual
Prefix:
First Name:JERALYN
Middle Name:NICOLE
Last Name:GIFFEN
Suffix:
Gender:F
Credentials:MSW,LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3990 CYPRESS CT
Mailing Address - Street 2:
Mailing Address - City:AMELIA
Mailing Address - State:OH
Mailing Address - Zip Code:45102-7517
Mailing Address - Country:US
Mailing Address - Phone:765-580-1470
Mailing Address - Fax:
Practice Address - Street 1:7 HANSBRINKER CT
Practice Address - Street 2:
Practice Address - City:LIBERTY TOWNSHIP
Practice Address - State:OH
Practice Address - Zip Code:45044-9737
Practice Address - Country:US
Practice Address - Phone:765-580-1470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-12
Last Update Date:2019-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS11003691041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool