1205066024 NPI number — KRISTA M JONES LISW

Table of content: KRISTA M JONES LISW (NPI 1205066024)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205066024 NPI number — KRISTA M JONES LISW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JONES
Provider First Name:
KRISTA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LISW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ADAMCZYK
Provider Other First Name:
KRISTA
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LISW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1205066024
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/26/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3737 LANDER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEPPER PIKE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44124-5712
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-324-4980
Provider Business Mailing Address Fax Number:
440-324-4987

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
347 MIDWAY BLVD
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
ELYRIA
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44035-9006
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-324-4980
Provider Business Practice Location Address Fax Number:
440-324-4987
Provider Enumeration Date:
07/15/2009

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: 104100000X , with the licence number:  S.0701513 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: I.1000083 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0268768 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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