=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528676848
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAY C. STEVENS LPN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2020
-----------------------------------------------------
Last Update Date | 07/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 55 W SMILEY AVE
-----------------------------------------------------
City | SHELBY
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44875-1004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-631-6957
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 55 W SMILEY AVE
-----------------------------------------------------
City | SHELBY
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44875-1004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-631-6957
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | LPN.163460.MEDS-IV
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------