Basic Information
| Provider Information | |||||||||
| NPI: | 1851764575 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BASTIAN | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2899 MINGO RD | ||||||||
| Address2: | |||||||||
| City: | CHILLICOTHE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456018762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404852416 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 102 DAWN LN | ||||||||
| Address2: | |||||||||
| City: | WAVERLY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456909695 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7409477783 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2015 | ||||||||
| LastUpdateDate: | 12/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | S.1502311 | OH | Y | Behavioral Health & Social Service Providers | Social Worker | 104100000X | N | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 0279524 | 05 | OH | MEDICAID |