Provider Demographics
NPI:1497210819
Name:GERONIMO, JACLYN EMILIE (APRN)
Entity Type:Individual
Prefix:MRS
First Name:JACLYN
Middle Name:EMILIE
Last Name:GERONIMO
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MISS
Other - First Name:JACLYN
Other - Middle Name:EMILIE
Other - Last Name:DISHOP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:4510 DORR ST # MS 840
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43615-4040
Mailing Address - Country:US
Mailing Address - Phone:419-383-6843
Mailing Address - Fax:419-383-3338
Practice Address - Street 1:2142 N COVE BLVD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-3895
Practice Address - Country:US
Practice Address - Phone:419-591-6460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-11
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.024133363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0356604Medicaid