Provider Demographics
NPI:1932514122
Name:FAUGHT, JEANA A
Entity Type:Individual
Prefix:
First Name:JEANA
Middle Name:A
Last Name:FAUGHT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:84 WEIL AVE
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44319-3048
Mailing Address - Country:US
Mailing Address - Phone:330-715-8863
Mailing Address - Fax:
Practice Address - Street 1:84 WEIL AVE
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44319-3048
Practice Address - Country:US
Practice Address - Phone:330-715-8863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-25
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0097747172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0097747Medicaid