Provider Demographics
NPI:1275406159
Name:JACK, WENDY P (DSP)
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:P
Last Name:JACK
Suffix:
Gender:F
Credentials:DSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25020 MILL RIVER RD
Mailing Address - Street 2:
Mailing Address - City:OLMSTED FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44138-2000
Mailing Address - Country:US
Mailing Address - Phone:440-724-1462
Mailing Address - Fax:
Practice Address - Street 1:25020 MILL RIVER RD
Practice Address - Street 2:
Practice Address - City:OLMSTED FALLS
Practice Address - State:OH
Practice Address - Zip Code:44138-2000
Practice Address - Country:US
Practice Address - Phone:440-724-1462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-26
Last Update Date:2025-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRP985477172A00000X
OH3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No172A00000XOther Service ProvidersDriver