Basic Information
| Provider Information | |||||||||
| NPI: | 1467992271 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLICK | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 204 COOK RD | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450369600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132287800 | ||||||||
| FaxNumber: | 5137252231 | ||||||||
| Practice Location | |||||||||
| Address1: | 50 GREENWOOD LN | ||||||||
| Address2: | |||||||||
| City: | SPRINGBORO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450663033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377461154 | ||||||||
| FaxNumber: | 9377468523 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2017 | ||||||||
| LastUpdateDate: | 08/13/2019 | ||||||||
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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 | 1041C0700X | S.1903747 | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 0355398 | 05 | OH | MEDICAID |