Basic Information
| Provider Information | |||||||||
| NPI: | 1477566396 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HORD | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LISW-S | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PHILBRICK | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LISW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 817 | ||||||||
| Address2: | |||||||||
| City: | WEST LIBERTY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 433570817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374658065 | ||||||||
| FaxNumber: | 9374650442 | ||||||||
| Practice Location | |||||||||
| Address1: | 715 S. PLUM ST | ||||||||
| Address2: | |||||||||
| City: | MARYSVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9376449192 | ||||||||
| FaxNumber: | 9376443426 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2006 | ||||||||
| LastUpdateDate: | 12/04/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | S0500314 | OH | N | Behavioral Health & Social Service Providers | Social Worker | 104100000X | I0800242 | OH | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | S0500314 | 01 | OH | LSW | OTHER |