Provider Demographics
NPI:1104493006
Name:BLEDSOE, JACQUELINE MARIE (STNA)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MARIE
Last Name:BLEDSOE
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1081 DELIA AVE
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44320-2060
Mailing Address - Country:US
Mailing Address - Phone:234-205-8212
Mailing Address - Fax:
Practice Address - Street 1:1081 DELIA AVE
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44320-2060
Practice Address - Country:US
Practice Address - Phone:234-205-8212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-08
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health