Provider Demographics
NPI:1689853418
Name:HAAS, JACQUELYN G (AT)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:G
Last Name:HAAS
Suffix:
Gender:F
Credentials:AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4701 CREEK RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45242-8398
Mailing Address - Country:US
Mailing Address - Phone:513-733-9333
Mailing Address - Fax:513-588-2479
Practice Address - Street 1:1555 CENTRAL PARKWAY
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45214-2863
Practice Address - Country:US
Practice Address - Phone:513-381-4901
Practice Address - Fax:513-381-4903
Is Sole Proprietor?:No
Enumeration Date:2007-10-29
Last Update Date:2011-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT.0008402255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0225920002Medicare NSC