Provider Demographics
NPI:1891218376
Name:DAVIS, JACQUELINE DENISE (STNA / OCDT)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:DENISE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:STNA / OCDT
Other - Prefix:MRS
Other - First Name:JACQUELINE
Other - Middle Name:DENISE
Other - Last Name:DUFFIELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5340 M ST NE
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:OH
Mailing Address - Zip Code:44643-8466
Mailing Address - Country:US
Mailing Address - Phone:440-213-5996
Mailing Address - Fax:
Practice Address - Street 1:5340 M ST NE
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:OH
Practice Address - Zip Code:44643-8466
Practice Address - Country:US
Practice Address - Phone:440-213-5996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty