Provider Demographics
NPI:1124163670
Name:DAVIS, JENNIFER (LISW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:DAVIS
Suffix:
Gender:
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4004 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45403-2242
Mailing Address - Country:US
Mailing Address - Phone:937-475-8391
Mailing Address - Fax:
Practice Address - Street 1:4004 E 3RD ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45403-2242
Practice Address - Country:US
Practice Address - Phone:937-474-8391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.00023161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND000000012188OtherANTHEM
OH007792009OtherMAGELLAN