Provider Demographics
NPI:1215403506
Name:PERRY, JACKIE RENEA' (LPN)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:RENEA'
Last Name:PERRY
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 1:2888 VALLEYVIEW DR
Mailing Address - Street 2:
Mailing Address - City:FAIRBORN
Mailing Address - State:OH
Mailing Address - Zip Code:45324-2252
Mailing Address - Country:US
Mailing Address - Phone:937-603-9841
Mailing Address - Fax:
Practice Address - Street 1:4350 APPLETON PLACE
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45440-4532
Practice Address - Country:US
Practice Address - Phone:937-603-9841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-15
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH137852.MEDS-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse