Provider Demographics
NPI:1982064432
Name:DENNIS, JACQUELYN M (CNP)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELYN
Middle Name:M
Last Name:DENNIS
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1207 W STATE ST
Mailing Address - Street 2:SUITE N
Mailing Address - City:ALLIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:44601-4686
Mailing Address - Country:US
Mailing Address - Phone:330-821-3244
Mailing Address - Fax:330-868-5782
Practice Address - Street 1:1207 W STATE ST
Practice Address - Street 2:SUITE N
Practice Address - City:ALLIANCE
Practice Address - State:OH
Practice Address - Zip Code:44601-4686
Practice Address - Country:US
Practice Address - Phone:330-821-3244
Practice Address - Fax:330-868-5782
Is Sole Proprietor?:No
Enumeration Date:2016-02-26
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.18811-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH168552Medicaid
OHH462660Medicare UPIN