Basic Information
| Provider Information | |||||||||
| NPI: | 1366734279 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DECLERCQ | ||||||||
| FirstName: | JAMIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | LISW-SUPV | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 SHAWNEE RD | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458053583 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4199993607 | ||||||||
| FaxNumber: | 4199996284 | ||||||||
| Practice Location | |||||||||
| Address1: | 2535 FORT AMANDA RD | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4199992055 | ||||||||
| FaxNumber: | 4199992058 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2011 | ||||||||
| LastUpdateDate: | 05/29/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | I0031486-SUPV | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 0251480 | 05 | OH | MEDICAID |