Basic Information
| Provider Information | |||||||||
| NPI: | 1194054916 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEMALINE | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | SUE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | L.S.W. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | POTTER | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | SUE | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | L.S.W. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 701 JEFFERSON AVE | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436046955 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192445511 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7320 STATE HUGHWAY 108 | ||||||||
| Address2: | SUITE A | ||||||||
| City: | WAUSEON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193353732 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2009 | ||||||||
| LastUpdateDate: | 12/08/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | S.0031417 | OH | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.