Provider Demographics
NPI:1144310368
Name:TOTH, JACKIE LYNN (LPN)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:LYNN
Last Name:TOTH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 FOREST DR
Mailing Address - Street 2:
Mailing Address - City:EASTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44095-1500
Mailing Address - Country:US
Mailing Address - Phone:440-951-2146
Mailing Address - Fax:
Practice Address - Street 1:45 FOREST DR
Practice Address - Street 2:
Practice Address - City:EASTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44095-1500
Practice Address - Country:US
Practice Address - Phone:440-951-2146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN085650164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2268693Medicare ID - Type UnspecifiedPROVIDER #