Provider Demographics
NPI:1497320790
Name:DELOST, JENNIFER LEE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEE
Last Name:DELOST
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 1:6500 ROCKSIDE RD STE 160
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:OH
Mailing Address - Zip Code:44131-2319
Mailing Address - Country:US
Mailing Address - Phone:216-447-9704
Mailing Address - Fax:
Practice Address - Street 1:6500 ROCKSIDE RD STE 160
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:OH
Practice Address - Zip Code:44131-2319
Practice Address - Country:US
Practice Address - Phone:216-447-9704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-20
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0028914363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner