Provider Demographics
NPI:1154391282
Name:SHOEMAKER, JEAN M (LISW-S RPT-S)
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:M
Last Name:SHOEMAKER
Suffix:
Gender:F
Credentials:LISW-S RPT-S
Other - Prefix:
Other - First Name:JEAN
Other - Middle Name:M
Other - Last Name:CLARE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:131 N MAIN ST STE K
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43040-1191
Mailing Address - Country:US
Mailing Address - Phone:937-441-3448
Mailing Address - Fax:
Practice Address - Street 1:131 N MAIN ST STE K
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040
Practice Address - Country:US
Practice Address - Phone:937-441-3448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH10122-S1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0195602Medicaid