Provider Demographics
NPI:1043208788
Name:JEAN, EDNA MARIE
Entity Type:Individual
Prefix:
First Name:EDNA
Middle Name:MARIE
Last Name:JEAN
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:PO BOX 2969
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-0969
Mailing Address - Country:US
Mailing Address - Phone:419-537-9877
Mailing Address - Fax:419-537-9878
Practice Address - Street 1:1857 N REYNOLDS RD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43615-3537
Practice Address - Country:US
Practice Address - Phone:419-537-9877
Practice Address - Fax:419-537-9878
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-06
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36-00-2601-J213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0765908Medicaid
OHJE0655502Medicare PIN
OH0276480001Medicare NSC
OH0765908Medicaid