Provider Demographics
NPI:1417473406
Name:JEWELL, CARRILYNN EVELYN ELAYNE
Entity Type:Individual
Prefix:
First Name:CARRILYNN
Middle Name:EVELYN ELAYNE
Last Name:JEWELL
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 1:702 RAVINE AVE
Mailing Address - Street 2:
Mailing Address - City:DEFIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:43512-3148
Mailing Address - Country:US
Mailing Address - Phone:419-980-5978
Mailing Address - Fax:
Practice Address - Street 1:702 RAVINE AVE
Practice Address - Street 2:
Practice Address - City:DEFIANCE
Practice Address - State:OH
Practice Address - Zip Code:43512-3148
Practice Address - Country:US
Practice Address - Phone:419-980-5978
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHUD592568374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHA0P170975-01OtherPARAMOUNT ADVANTAGE
OHA00170975OtherPARAMOUNT ADVANTAGE