Provider Demographics
NPI:1205522414
Name:JACK, MAUREEN
Entity type:Individual
Prefix:
First Name:MAUREEN
Middle Name:
Last Name:JACK
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 1:2625 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:HINCKLEY
Mailing Address - State:OH
Mailing Address - Zip Code:44233-9790
Mailing Address - Country:US
Mailing Address - Phone:216-712-9916
Mailing Address - Fax:
Practice Address - Street 1:7841 WEST RIDGEWOOD DRIVE
Practice Address - Street 2:SUITE 815
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44129
Practice Address - Country:US
Practice Address - Phone:216-712-9916
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-12
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0033178363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily