Provider Demographics
NPI:1467100404
Name:GENTRY, JATANA
Entity Type:Individual
Prefix:
First Name:JATANA
Middle Name:
Last Name:GENTRY
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:PO BOX 308
Mailing Address - Street 2:
Mailing Address - City:WAYNESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45068-0308
Mailing Address - Country:US
Mailing Address - Phone:520-658-8892
Mailing Address - Fax:
Practice Address - Street 1:459 MARY LN
Practice Address - Street 2:
Practice Address - City:SOUTH LEBANON
Practice Address - State:OH
Practice Address - Zip Code:45065-1315
Practice Address - Country:US
Practice Address - Phone:520-658-8892
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-17
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No172A00000XOther Service ProvidersDriver
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant