Provider Demographics
NPI:1982989679
Name:TATE, JACQUELINE JULIET (NON PAR PROVIDER)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:JULIET
Last Name:TATE
Suffix:
Gender:F
Credentials:NON PAR PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 HINGHAM LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43224-3725
Mailing Address - Country:US
Mailing Address - Phone:614-800-9745
Mailing Address - Fax:
Practice Address - Street 1:2600 HINGHAM LN
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43224-3725
Practice Address - Country:US
Practice Address - Phone:614-800-9748
Practice Address - Fax:614-934-5732
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-13
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0053979Medicaid
OH1982989679OtherWAIVER PROVIDER