Provider Demographics
NPI:1922244953
Name:EDNA MARIE JEAN
Entity Type:Organization
Organization Name:EDNA MARIE JEAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:
Authorized Official - First Name:EDNA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:JEAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:419-537-9877
Mailing Address - Street 1:1857 N REYNOLDS RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43615-3537
Mailing Address - Country:US
Mailing Address - Phone:419-537-9877
Mailing Address - Fax:
Practice Address - Street 1:1857 N REYNOLDS RD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43615-3537
Practice Address - Country:US
Practice Address - Phone:419-537-9877
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-22
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36.002601332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0765908Medicaid
OH0765908Medicaid
OHT92702Medicare UPIN
OHJE0655502Medicare PIN