Provider Demographics
NPI:1265236400
Name:LILES, JACKIE SUE (LPN)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:SUE
Last Name:LILES
Suffix:
Gender:
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3209 TOWNSHIP ROAD 31 N
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43324-7501
Mailing Address - Country:US
Mailing Address - Phone:937-869-2256
Mailing Address - Fax:
Practice Address - Street 1:3209 TOWNSHIP ROAD 31 N
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43324-7501
Practice Address - Country:US
Practice Address - Phone:937-869-2256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-04
Last Update Date:2025-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN124987-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse