Provider Demographics
NPI:1922236504
Name:GAINES-JACKSON, CHAUNTYSE DANIELLE (LPN)
Entity Type:Individual
Prefix:
First Name:CHAUNTYSE
Middle Name:DANIELLE
Last Name:GAINES-JACKSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2257 BENTON AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45406-1803
Mailing Address - Country:US
Mailing Address - Phone:937-405-5433
Mailing Address - Fax:
Practice Address - Street 1:2257 BENTON AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45406-1803
Practice Address - Country:US
Practice Address - Phone:937-405-5433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-23
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN106190164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse