Provider Demographics
NPI:1235501669
Name:MYTYK, JEANNETTE CHRISTINE
Entity Type:Individual
Prefix:MRS
First Name:JEANNETTE
Middle Name:CHRISTINE
Last Name:MYTYK
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 1:1186 HADCOCK RD
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:OH
Mailing Address - Zip Code:44212-3016
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1186 HADCOCK RD
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:OH
Practice Address - Zip Code:44212-3016
Practice Address - Country:US
Practice Address - Phone:330-225-3156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-25
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2321026Medicaid
OH5211952Medicaid