MEDICARE: JAYLN MCKENZIE STACKHOUSE

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	363LA2200X	Adult Health Nurse Practitioner	RN.498975	OH

General Provider Information

NPI Number	:	1467306001
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAYLN MCKENZIE STACKHOUSE

Provider Business Mailing Address
First Line	:	2905 REPRESENTATION TER
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43207-6562
Country	:	US
Telephone Number	:	740-408-0497
Fax Number	:

Provider Business Practice Location Address
First Line	:	2905 REPRESENTATION TER
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43207-6562
Country	:	US
Telephone Number	:	740-408-0497
Fax Number	:

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

Provider Enumeration Date	:	02/23/2026
Last Update Date	:	02/23/2026

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