Provider Demographics
NPI:1548807316
Name:BISMACK, JENNIFER MARIE (CPRS, CPSS)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:MARIE
Last Name:BISMACK
Suffix:
Gender:F
Credentials:CPRS, CPSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 23RD ST
Mailing Address - Street 2:SUITE 911
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604
Mailing Address - Country:US
Mailing Address - Phone:419-509-6570
Mailing Address - Fax:
Practice Address - Street 1:142 23RD ST
Practice Address - Street 2:SUITE 911
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43604
Practice Address - Country:US
Practice Address - Phone:419-509-6570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-29
Last Update Date:2019-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0001315175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist