Provider Demographics
NPI:1730718941
Name:VANDRIEST, JACQUELINE MARIE
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MARIE
Last Name:VANDRIEST
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 1:525 METRO PL N
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017-5342
Mailing Address - Country:US
Mailing Address - Phone:614-339-1649
Mailing Address - Fax:
Practice Address - Street 1:2775 STATE ROUTE 39
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:OH
Practice Address - Zip Code:44875-9466
Practice Address - Country:US
Practice Address - Phone:419-747-3322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-08
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.171696.MEDS-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2910854Medicaid