Provider Demographics
NPI:1124084777
Name:SUPPAN, JACQUELINE ANN (MSN, CNS)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ANN
Last Name:SUPPAN
Suffix:
Gender:F
Credentials:MSN, CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2825 E PARADISE STREET EXT
Mailing Address - Street 2:
Mailing Address - City:ORRVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44667-9621
Mailing Address - Country:US
Mailing Address - Phone:330-683-2408
Mailing Address - Fax:
Practice Address - Street 1:733 MARKET AVE S
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44702-2165
Practice Address - Country:US
Practice Address - Phone:330-489-4600
Practice Address - Fax:216-229-2642
Is Sole Proprietor?:No
Enumeration Date:2006-04-24
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCTP-06570364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health