Healthcare Provider Details

I. General information

NPI: 1831134501
Provider Name (Legal Business Name): JACKSON-VINTON COMMUNITY ACTION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 S NEW YORK AVE
WELLSTON OH
45692-1540
US

IV. Provider business mailing address

118 S NEW YORK AVE
WELLSTON OH
45692-1540
US

V. Phone/Fax

Practice location:
  • Phone: 740-384-3722
  • Fax: 740-384-5405
Mailing address:
  • Phone: 740-384-3722
  • Fax: 740-384-5405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. CHERYL THIESSEN
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 740-384-3722