1104976208 NPI number — MS. VANESSA MARIE FORD LPCA

Table of content: MS. VANESSA MARIE FORD LPCA (NPI 1104976208)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104976208 NPI number — MS. VANESSA MARIE FORD LPCA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FORD
Provider First Name:
VANESSA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LPCA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JENNINGS
Provider Other First Name:
VANESSA
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1104976208
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 132
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATHENS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45701-0132
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-321-8293
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1450 COLUMBUS AVE STE 105
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WASHINGTON COURT HOUSE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43160-3701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-321-8293
Provider Business Practice Location Address Fax Number:
208-493-4900
Provider Enumeration Date:
01/11/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  340 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: LPC-3865 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 172V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 30615058 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".