Provider Demographics
NPI:1861874307
Name:EDWARDS, JENNA B (LISW)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:B
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:
Other - Last Name:HOOSIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 933421
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44193-0039
Mailing Address - Country:US
Mailing Address - Phone:937-641-5072
Mailing Address - Fax:937-641-6129
Practice Address - Street 1:3333 W TECH RD STE 220
Practice Address - Street 2:
Practice Address - City:MIAMISBURG
Practice Address - State:OH
Practice Address - Zip Code:45342-0956
Practice Address - Country:US
Practice Address - Phone:937-885-4475
Practice Address - Fax:937-885-3670
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-21
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.21032001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0466933Medicaid