MEDICARE: JAQUAYLA M HERRON

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	164W00000X	Licensed Practical Nurse	165687	OH

General Provider Information

NPI Number	:	1669979993
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAQUAYLA M HERRON

Provider Business Mailing Address
First Line	:	5716 GREENPINE ST
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43232-7754
Country	:	US
Telephone Number	:	419-371-1072
Fax Number	:

Provider Business Practice Location Address
First Line	:	1360 DUBLIN RD
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43215-1029
Country	:	US
Telephone Number	:	614-488-7117
Fax Number	:

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

Provider Enumeration Date	:	04/12/2018
Last Update Date	:	04/12/2018

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