Provider Demographics
NPI:1124084777
Name:SUPPAN, JACQUELINE ANN (MSN, CNS)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ANN
Last Name:SUPPAN
Suffix:
Gender:F
Credentials:MSN, CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2825 E PARADISE STREET EXT
Mailing Address - Street 2:
Mailing Address - City:ORRVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44667-9621
Mailing Address - Country:US
Mailing Address - Phone:330-234-0935
Mailing Address - Fax:
Practice Address - Street 1:1740 CLEVELAND RD
Practice Address - Street 2:
Practice Address - City:WOOSTER
Practice Address - State:OH
Practice Address - Zip Code:44691-2204
Practice Address - Country:US
Practice Address - Phone:330-287-4500
Practice Address - Fax:330-287-4929
Is Sole Proprietor?:No
Enumeration Date:2006-04-24
Last Update Date:2025-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCTP-06570364SA2200X
OHAPRN.CNP.0036720363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health