Provider Demographics
NPI:1275731713
Name:GIFFORD, JACQUELYNE BETH (LPN)
Entity Type:Individual
Prefix:
First Name:JACQUELYNE
Middle Name:BETH
Last Name:GIFFORD
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 1:383 COUNTY ROAD 1183
Mailing Address - Street 2:
Mailing Address - City:NOVA
Mailing Address - State:OH
Mailing Address - Zip Code:44859-9745
Mailing Address - Country:US
Mailing Address - Phone:419-652-2570
Mailing Address - Fax:
Practice Address - Street 1:383 COUNTY ROAD 1183
Practice Address - Street 2:
Practice Address - City:NOVA
Practice Address - State:OH
Practice Address - Zip Code:44859-9745
Practice Address - Country:US
Practice Address - Phone:419-652-2570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN 030761164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse