Provider Demographics
NPI:1114630100
Name:BAILEY, JOHNATHAN
Entity Type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:
Last Name:BAILEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63171 INSTITUTE RD
Mailing Address - Street 2:
Mailing Address - City:LORE CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43755-9754
Mailing Address - Country:US
Mailing Address - Phone:740-255-1005
Mailing Address - Fax:
Practice Address - Street 1:63171 INSTITUTE RD
Practice Address - Street 2:
Practice Address - City:LORE CITY
Practice Address - State:OH
Practice Address - Zip Code:43755-9754
Practice Address - Country:US
Practice Address - Phone:740-255-1005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-04
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0398579Medicaid