Provider Demographics
NPI:1417321258
Name:MELNYK, JACQUELINE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:MELNYK
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 1:415 DILLROSE DR
Mailing Address - Street 2:
Mailing Address - City:NORTHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:43619-1111
Mailing Address - Country:US
Mailing Address - Phone:419-346-2893
Mailing Address - Fax:419-666-0781
Practice Address - Street 1:415 DILLROSE DR
Practice Address - Street 2:
Practice Address - City:NORTHWOOD
Practice Address - State:OH
Practice Address - Zip Code:43619-1111
Practice Address - Country:US
Practice Address - Phone:419-346-2893
Practice Address - Fax:419-666-0781
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-17
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHC0003949801OtherMY CARE OHIO