MEDICARE: JACQUELINE YVONNE KING

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	374U00000X	Home Health Aide		OH

General Provider Information

NPI Number	:	1073145439
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE YVONNE KING

Provider Business Mailing Address
First Line	:	3727 SOFT WIND DR
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43232-6533
Country	:	US
Telephone Number	:	614-679-6114
Fax Number	:

Provider Business Practice Location Address
First Line	:	3727 SOFT WIND DR
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43232-6533
Country	:	US
Telephone Number	:	614-679-6114
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/04/2020
Last Update Date	:	02/04/2020

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