Provider Demographics
NPI:1104238914
Name:BROSTEK, JESSICA L (LISW)
Entity type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:L
Last Name:BROSTEK
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:L
Other - Last Name:BARIBEAU
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LISW
Mailing Address - Street 1:2075 AVON BELDEN RD
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:OH
Mailing Address - Zip Code:44044-9805
Mailing Address - Country:US
Mailing Address - Phone:440-748-1049
Mailing Address - Fax:
Practice Address - Street 1:2075 AVON BELDEN RD
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:OH
Practice Address - Zip Code:44044-9805
Practice Address - Country:US
Practice Address - Phone:440-748-1049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-28
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS1000238104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker