Provider Demographics
NPI:1568060523
Name:WOLGAMOTT, JACKIE E
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:E
Last Name:WOLGAMOTT
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 1:111 FORREST AVE
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45135-9620
Mailing Address - Country:US
Mailing Address - Phone:330-260-0311
Mailing Address - Fax:
Practice Address - Street 1:111 FORREST AVE
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:OH
Practice Address - Zip Code:45135-9620
Practice Address - Country:US
Practice Address - Phone:330-260-0311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-13
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0105027374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0105027Medicaid