Healthcare Provider Details

I. General information

NPI: 1528639788
Provider Name (Legal Business Name): JODI LORAIN SELF RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2021
Last Update Date: 07/08/2021
Certification Date: 07/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 NEON ST
SPRINGFIELD OH
45503-1880
US

IV. Provider business mailing address

2222 NEON ST
SPRINGFIELD OH
45503-1880
US

V. Phone/Fax

Practice location:
  • Phone: 937-688-0464
  • Fax:
Mailing address:
  • Phone: 937-688-0464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number391070
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: