Provider Demographics
NPI:1083606610
Name:SHRIVER, JACQUELINE S (CRNP)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:S
Last Name:SHRIVER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 SAINT CLAIR AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:OH
Mailing Address - Zip Code:45885-2400
Mailing Address - Country:US
Mailing Address - Phone:419-300-1129
Mailing Address - Fax:419-394-9575
Practice Address - Street 1:1140 S KNOXVILLE AVE STE B
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:OH
Practice Address - Zip Code:45885-2609
Practice Address - Country:US
Practice Address - Phone:419-394-7314
Practice Address - Fax:419-394-7313
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP2122363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9934723OtherGROUP MEDICARE
OH1184652539OtherGROUP NPI
OH0742307Medicaid
OHH561340OtherMEDICARE PTAN
OH0105065OtherMEDICAID GROUP
OH34-1689161OtherGROUP TAX ID
OHNP05475Medicare PIN
OHNP05473Medicare PIN
OHNP05474Medicare PIN