Provider Demographics
NPI:1558968677
Name:DOTHARD, JAQUAILA CORRANN
Entity Type:Individual
Prefix:
First Name:JAQUAILA
Middle Name:CORRANN
Last Name:DOTHARD
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 1:1501 WAKEFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44514-1060
Mailing Address - Country:US
Mailing Address - Phone:330-775-6119
Mailing Address - Fax:
Practice Address - Street 1:1501 WAKEFIELD AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44514-1060
Practice Address - Country:US
Practice Address - Phone:330-775-6119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-01
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHTD043829374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHTD048329Medicaid