Provider Demographics
NPI:1730269358
Name:WORTHINGTON, JERRY L (LICDC, LSW)
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:L
Last Name:WORTHINGTON
Suffix:
Gender:M
Credentials:LICDC, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 BUTTLES AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-1450
Mailing Address - Country:US
Mailing Address - Phone:614-228-7275
Mailing Address - Fax:614-228-7289
Practice Address - Street 1:11 BUTTLES AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-1450
Practice Address - Country:US
Practice Address - Phone:614-228-7275
Practice Address - Fax:614-228-7289
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH852134101YA0400X
OHS-00014851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical