Healthcare Provider Details

I. General information

NPI: 1336094390
Provider Name (Legal Business Name): JACKIE WILLMS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2026
Last Update Date: 03/03/2026
Certification Date: 03/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2145 STAGHORN WAY
GROVE CITY OH
43123-4873
US

IV. Provider business mailing address

2145 STAGHORN WAY
GROVE CITY OH
43123-4873
US

V. Phone/Fax

Practice location:
  • Phone: 330-419-1080
  • Fax:
Mailing address:
  • Phone: 330-419-1080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: