=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942913231
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNA DELOVE SIMMONS LPN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/02/2023
-----------------------------------------------------
Last Update Date | 01/02/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4011 E 55TH ST # UP
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44105-4840
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-512-9963
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4011 E 55TH ST # UP
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44105-4840
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-512-9963
-----------------------------------------------------
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 | 183548
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------