Provider Demographics
NPI:1376037937
Name:WISE, JACQUELINE K (MS, ATC)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:K
Last Name:WISE
Suffix:
Gender:F
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44115-2226
Mailing Address - Country:US
Mailing Address - Phone:216-687-4806
Mailing Address - Fax:216-687-9267
Practice Address - Street 1:2121 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44115-2226
Practice Address - Country:US
Practice Address - Phone:216-687-4806
Practice Address - Fax:216-687-9267
Is Sole Proprietor?:No
Enumeration Date:2018-06-18
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT-16862255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer