Basic Information
Provider Information | |||||||||
NPI: | 1528470424 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CORSER | ||||||||
FirstName: | JESSICA | ||||||||
MiddleName: | CHARLENE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LISW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MORRIS | ||||||||
OtherFirstName: | JESSICA | ||||||||
OtherMiddleName: | CHARLENE | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LSW | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2837 SHERBROOKE RD | ||||||||
Address2: |   | ||||||||
City: | TOLEDO | ||||||||
State: | OH | ||||||||
PostalCode: | 436063746 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9176234119 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 508 N HAWLEY ST | ||||||||
Address2: |   | ||||||||
City: | TOLEDO | ||||||||
State: | OH | ||||||||
PostalCode: | 436074476 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4192554050 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/27/2014 | ||||||||
LastUpdateDate: | 05/27/2014 | ||||||||
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 | 1041C0700X | I.1440430 | OH | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.