Provider Demographics
NPI:1316146988
Name:LAINE, JACLYN MAUREEN (DO)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:MAUREEN
Last Name:LAINE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:MAUREEN
Other - Last Name:DRAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO,
Mailing Address - Street 1:PO BOX 7527
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017-0727
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1480 W LANE AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43221-3919
Practice Address - Country:US
Practice Address - Phone:614-533-5500
Practice Address - Fax:614-533-0103
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.0101952084N0400X, 2084N0600X, 2084E0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084E0001XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyEpilepsy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0061403Medicaid
OH0061403Medicaid