Provider Demographics
NPI:1285618645
Name:GODFREY, JANE A (PHD LISW)
Entity type:Individual
Prefix:DR
First Name:JANE
Middle Name:A
Last Name:GODFREY
Suffix:
Gender:F
Credentials:PHD LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4979 MAYFIELD RD
Mailing Address - Street 2:
Mailing Address - City:LYNDHURST
Mailing Address - State:OH
Mailing Address - Zip Code:44124-2601
Mailing Address - Country:US
Mailing Address - Phone:216-839-2273
Mailing Address - Fax:216-896-0735
Practice Address - Street 1:4979 MAYFIELD RD
Practice Address - Street 2:
Practice Address - City:LYNDHURST
Practice Address - State:OH
Practice Address - Zip Code:44124-2601
Practice Address - Country:US
Practice Address - Phone:216-839-2273
Practice Address - Fax:216-896-0735
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI4619104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
S36859Medicare UPIN
OHSW17162Medicare PIN