Provider Demographics
NPI:1003325812
Name:REDICK, JWAUN R
Entity Type:Individual
Prefix:MRS
First Name:JWAUN
Middle Name:R
Last Name:REDICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 BIRUTA ST
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44307-1014
Mailing Address - Country:US
Mailing Address - Phone:330-573-7923
Mailing Address - Fax:
Practice Address - Street 1:1000 BIRUTA ST
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44307-1014
Practice Address - Country:US
Practice Address - Phone:330-573-9302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-25
Last Update Date:2017-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH400123640602376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0224338Medicaid