Provider Demographics
NPI:1114146750
Name:CLOUSE, JACKIE ELAINE
Entity Type:Individual
Prefix:MS
First Name:JACKIE
Middle Name:ELAINE
Last Name:CLOUSE
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 1:10005 KNOWLTON RD
Mailing Address - Street 2:
Mailing Address - City:GARRETTSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44231-9793
Mailing Address - Country:US
Mailing Address - Phone:330-322-1965
Mailing Address - Fax:
Practice Address - Street 1:13231 BUTTERNUT RD
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:OH
Practice Address - Zip Code:44021-9567
Practice Address - Country:US
Practice Address - Phone:440-834-1089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor