Healthcare Provider Details

I. General information

NPI: 1023749983
Provider Name (Legal Business Name): JACLYN CARR NP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JACLYN NOES

II. Dates (important events)

Enumeration Date: 06/22/2022
Last Update Date: 05/16/2024
Certification Date: 05/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5735 MEEKER RD
GREENVILLE OH
45331-1186
US

IV. Provider business mailing address

5735 MEEKER RD
GREENVILLE OH
45331-1186
US

V. Phone/Fax

Practice location:
  • Phone: 937-548-9680
  • Fax: 937-548-2087
Mailing address:
  • Phone: 937-548-9680
  • Fax: 937-548-2087

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.0030540
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAPRN.CNP.0030540
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: