Provider Demographics
NPI:1649765934
Name:MOTHERSHED, JIARON KEITH
Entity Type:Individual
Prefix:
First Name:JIARON
Middle Name:KEITH
Last Name:MOTHERSHED
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2023 KEY ST APT C
Mailing Address - Street 2:
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-2546
Mailing Address - Country:US
Mailing Address - Phone:419-320-4186
Mailing Address - Fax:
Practice Address - Street 1:624 MAIN ST
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43605-1777
Practice Address - Country:US
Practice Address - Phone:419-720-6811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-28
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH171M00000XMedicaid