Healthcare Provider Details

I. General information

NPI: 1740524941
Provider Name (Legal Business Name): JACKIE R PATTON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/12/2012
Last Update Date: 11/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 BROAD ST
GLOUSTER OH
45732-1127
US

IV. Provider business mailing address

29 BROAD ST
GLOUSTER OH
45732-1127
US

V. Phone/Fax

Practice location:
  • Phone: 740-856-9788
  • Fax: 740-767-2959
Mailing address:
  • Phone: 740-856-9788
  • Fax: 740-767-2959

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN 168364
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: