Provider Demographics
NPI:1114514718
Name:JAQUILLARD, SHIRLEY ANN
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:ANN
Last Name:JAQUILLARD
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 1:206 DULTON DR
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43615-9033
Mailing Address - Country:US
Mailing Address - Phone:419-376-0120
Mailing Address - Fax:
Practice Address - Street 1:206 DULTON DR
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43615-9033
Practice Address - Country:US
Practice Address - Phone:419-376-0120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-29
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide