Basic Information
| Provider Information | |||||||||
| NPI: | 1417414962 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURNSIDE | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | |||||||||
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| Credential: | LCDCIII | ||||||||
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| Mailing Information | |||||||||
| Address1: | 777 COLUMBUS AVE | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450361684 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 777 COLUMBUS AVE | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450361684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132286590 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2019 | ||||||||
| LastUpdateDate: | 02/20/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 991509 | OH | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 4752702 | 05 | OH | MEDICAID |