Provider Demographics
NPI:1851153712
Name:TELLEZ, JACKLYN
Entity Type:Individual
Prefix:
First Name:JACKLYN
Middle Name:
Last Name:TELLEZ
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 1:3160 SWOPE ST
Mailing Address - Street 2:
Mailing Address - City:TRINWAY
Mailing Address - State:OH
Mailing Address - Zip Code:43842-7729
Mailing Address - Country:US
Mailing Address - Phone:740-319-7704
Mailing Address - Fax:
Practice Address - Street 1:3160 SWOPE ST
Practice Address - Street 2:
Practice Address - City:TRINWAY
Practice Address - State:OH
Practice Address - Zip Code:43842-7729
Practice Address - Country:US
Practice Address - Phone:740-319-7704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-26
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHTC877796251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health