Basic Information
Provider Information | |||||||||
NPI: | 1235780958 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MEREDITH | ||||||||
FirstName: | JASMINE | ||||||||
MiddleName: | ALESIA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCDC III | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ORTIZ | ||||||||
OtherFirstName: | JASMINE | ||||||||
OtherMiddleName: | ALESIA | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LCDC III | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 6596 QUAIL CREEK DR | ||||||||
Address2: |   | ||||||||
City: | CANAL WINCHESTER | ||||||||
State: | OH | ||||||||
PostalCode: | 431109394 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6143270535 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2065 STONERIDGE DR | ||||||||
Address2: |   | ||||||||
City: | CIRCLEVILLE | ||||||||
State: | OH | ||||||||
PostalCode: | 431138956 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7405001391 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/24/2019 | ||||||||
LastUpdateDate: | 07/05/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/05/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X |   | OH | N |   | Other Service Providers | Case Manager/Care Coordinator |   | 101YA0400X | LCDCIII.162224 | OH | Y |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.