Provider Demographics
NPI:1679561492
Name:HOGAN, JACQUELINE R (MSN, CNP)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:R
Last Name:HOGAN
Suffix:
Gender:F
Credentials:MSN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5700 SOUTHWYCK BLVD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-1509
Mailing Address - Country:US
Mailing Address - Phone:800-288-8325
Mailing Address - Fax:419-866-5453
Practice Address - Street 1:1200 RALSTON AVENUE
Practice Address - Street 2:
Practice Address - City:DEFIANCE
Practice Address - State:OH
Practice Address - Zip Code:43512-1396
Practice Address - Country:US
Practice Address - Phone:419-783-5655
Practice Address - Fax:419-866-5453
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN110287163W00000X
OHNP05242363LF0000X
MI4704170468363LF0000X
OHCOA05242NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily