Healthcare Provider Details

I. General information

NPI: 1285836254
Provider Name (Legal Business Name): CAROL G JUTTE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1795 SAINT PETER RD
FORT RECOVERY OH
45846-9704
US

IV. Provider business mailing address

1795 SAINT PETER RD
FORT RECOVERY OH
45846-9704
US

V. Phone/Fax

Practice location:
  • Phone: 419-375-2609
  • Fax:
Mailing address:
  • Phone: 419-375-2609
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN 302332
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: