Provider Demographics
NPI:1841977105
Name:AYUKO, JACKLINE JERUSA (REGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:JACKLINE
Middle Name:JERUSA
Last Name:AYUKO
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4447 COVENTRY PKWY
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7105
Mailing Address - Country:US
Mailing Address - Phone:321-444-3325
Mailing Address - Fax:
Practice Address - Street 1:AUREUS MEDICAL GROUP
Practice Address - Street 2:13609 CALIFORNIA ST.
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-5260
Practice Address - Country:US
Practice Address - Phone:402-891-1118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-29
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28260037A376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376G00000XNursing Service Related ProvidersNursing Home Administrator