Provider Demographics
NPI:1770722878
Name:MALOTT, JENNIFER L (MSW, LSCW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:MALOTT
Suffix:
Gender:F
Credentials:MSW, LSCW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 E WASHINGTON BLVD
Mailing Address - Street 2:SUITE 700
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46803-1359
Mailing Address - Country:US
Mailing Address - Phone:260-422-3034
Mailing Address - Fax:
Practice Address - Street 1:2020 E WASHINGTON BLVD
Practice Address - Street 2:SUITE 700
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46803-1359
Practice Address - Country:US
Practice Address - Phone:260-422-3034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-12
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN33005516A104100000X
IN34006055A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker