MEDICARE: JAKIESHA PETTWAY REV

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3747P1801X	Personal Care Attendant
2	376J00000X	Homemaker

General Provider Information

NPI Number	:	1770312787
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAKIESHA PETTWAY REV

Provider Business Mailing Address
First Line	:	432 ELIZABETH ST
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45203-1425
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	432 ELIZABETH ST
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45203-1425
Country	:	US
Telephone Number	:	513-601-4032
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/29/2024
Last Update Date	:	07/29/2024

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Directions to “ JAKIESHA PETTWAY REV” Practice Location

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