Provider Demographics
NPI:1285293142
Name:ADRIAN, JACQUELINE DELAINE
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:DELAINE
Last Name:ADRIAN
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 1:3533 SOUTHERN BLVD STE 2100
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-1267
Mailing Address - Country:US
Mailing Address - Phone:937-395-8556
Mailing Address - Fax:937-395-6376
Practice Address - Street 1:3535 SOUTHERN BLVD STE 2100
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-1221
Practice Address - Country:US
Practice Address - Phone:937-395-8556
Practice Address - Fax:937-395-6376
Is Sole Proprietor?:No
Enumeration Date:2019-06-13
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNOP.024796363L00000X
OHAPRNCNP024796363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0362039Medicaid