Provider Demographics
NPI:1215757208
Name:WISE, JACQUELYN N
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:N
Last Name:WISE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 GUILFORD BLVD
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-2135
Mailing Address - Country:US
Mailing Address - Phone:330-590-7034
Mailing Address - Fax:
Practice Address - Street 1:250 GUILFORD BLVD
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-2135
Practice Address - Country:US
Practice Address - Phone:330-590-7034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-14
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No251X00000XAgenciesSupports Brokerage
No253Z00000XAgenciesIn Home Supportive Care
No347C00000XTransportation ServicesPrivate Vehicle
No372600000XNursing Service Related ProvidersAdult Companion
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No172A00000XOther Service ProvidersDriver
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No374U00000XNursing Service Related ProvidersHome Health Aide
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child