Provider Demographics
NPI:1922764760
Name:JEZAK, JACLYN NOEL MARIE (CNP)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:NOEL MARIE
Last Name:JEZAK
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 CHAMPLIN DR
Mailing Address - Street 2:
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-7178
Mailing Address - Country:US
Mailing Address - Phone:419-266-5297
Mailing Address - Fax:
Practice Address - Street 1:710 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:OH
Practice Address - Zip Code:43420-3224
Practice Address - Country:US
Practice Address - Phone:419-334-6619
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-16
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0030241363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health