Basic Information
| Provider Information | |||||||||
| NPI: | 1801260963 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SKIDMORE | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MSW, LISW-S, CTP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 400 | ||||||||
| Address2: | |||||||||
| City: | HOLLAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198417701 | ||||||||
| FaxNumber: | 4198411691 | ||||||||
| Practice Location | |||||||||
| Address1: | 6715 DORR ST. | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198681178 | ||||||||
| FaxNumber: | 4198681989 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2015 | ||||||||
| LastUpdateDate: | 09/03/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 1041C0700X | I.1502371 | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 0165312 | 05 | OH | MEDICAID |