Healthcare Provider Details

I. General information

NPI: 1528707106
Provider Name (Legal Business Name): JAQUON ANDRE MIXON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2022
Last Update Date: 06/01/2022
Certification Date: 06/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 FERNDALE AVE
YOUNGSTOWN OH
44511-3210
US

IV. Provider business mailing address

630 FERNDALE AVE
YOUNGSTOWN OH
44511-3210
US

V. Phone/Fax

Practice location:
  • Phone: 330-716-6710
  • Fax:
Mailing address:
  • Phone: 330-716-6710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: