Provider Demographics
NPI:1003479080
Name:RENNECKER, JAIME MARIE
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:MARIE
Last Name:RENNECKER
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 1:2600 6TH ST SW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44710-1702
Mailing Address - Country:US
Mailing Address - Phone:330-363-5433
Mailing Address - Fax:330-580-6785
Practice Address - Street 1:2600 SIXTH ST SW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44710-1702
Practice Address - Country:US
Practice Address - Phone:330-363-5433
Practice Address - Fax:330-363-7785
Is Sole Proprietor?:No
Enumeration Date:2019-04-16
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.019380363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal