Provider Demographics
NPI:1124375845
Name:MALLETT, JACLYN LENAI (LPN)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:LENAI
Last Name:MALLETT
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 CHEYENNE PL
Mailing Address - Street 2:
Mailing Address - City:TIPP CITY
Mailing Address - State:OH
Mailing Address - Zip Code:45371-1507
Mailing Address - Country:US
Mailing Address - Phone:757-770-7860
Mailing Address - Fax:
Practice Address - Street 1:750 CHEYENNE PL
Practice Address - Street 2:
Practice Address - City:TIPP CITY
Practice Address - State:OH
Practice Address - Zip Code:45371-1507
Practice Address - Country:US
Practice Address - Phone:757-770-7860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-13
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.144901-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse