Healthcare Provider Details

I. General information

NPI: 1639703200
Provider Name (Legal Business Name): JACQUELYN ANNE EUREKA RN, BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2020
Last Update Date: 05/13/2022
Certification Date: 05/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6605 CENTER RD
VALLEY CITY OH
44280-9748
US

IV. Provider business mailing address

17045 GREENWOOD DR
STRONGSVILLE OH
44149-5822
US

V. Phone/Fax

Practice location:
  • Phone: 330-483-3135
  • Fax:
Mailing address:
  • Phone: 330-636-1908
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.0026802
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number386857
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: