Provider Demographics
NPI:1972886943
Name:DAVIS, JACQUELINE JUNE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:JUNE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6544 RIVERBEND DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45415-2676
Mailing Address - Country:US
Mailing Address - Phone:937-416-3400
Mailing Address - Fax:
Practice Address - Street 1:2912 SPRINGBORO RD
Practice Address - Street 2:
Practice Address - City:MORAINE
Practice Address - State:OH
Practice Address - Zip Code:45439-1674
Practice Address - Country:US
Practice Address - Phone:937-297-8999
Practice Address - Fax:937-277-8618
Is Sole Proprietor?:No
Enumeration Date:2011-09-26
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA. 12542-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0054352Medicaid
OH000000742437OtherANTHEM BCBS OHIO
OH421534506182OtherCARESROUCE OHIO
OH421534506182OtherCARESROUCE OHIO