Provider Demographics
NPI:1922401843
Name:TAKALA, JACQUELINE (LPN)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:TAKALA
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 1:2060 MARION WILLIAMSPORT RD E
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-8219
Mailing Address - Country:US
Mailing Address - Phone:740-387-3764
Mailing Address - Fax:
Practice Address - Street 1:2060 MARION WILLIAMSPORT RD E
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-8219
Practice Address - Country:US
Practice Address - Phone:740-387-3764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-06
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN . 057313164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse