Provider Demographics
NPI:1194365692
Name:REAVES, JACQUELINE (LPN)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:REAVES
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:PO BOX 307514
Mailing Address - Street 2:
Mailing Address - City:GAHANNA
Mailing Address - State:OH
Mailing Address - Zip Code:43230-7514
Mailing Address - Country:US
Mailing Address - Phone:614-758-7700
Mailing Address - Fax:404-795-7118
Practice Address - Street 1:3993 LEATHER STOCKING TRL
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43230-1528
Practice Address - Country:US
Practice Address - Phone:614-806-8647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-13
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH142153164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH84-4156364Medicaid