Provider Demographics
NPI:1861053639
Name:GEDDES, JACLYN ROSE (CNP)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:ROSE
Last Name:GEDDES
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:ROSE
Other - Last Name:WUEBOLD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BSN, RN
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 1:3535 OLENTANGY RIVER RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-3908
Practice Address - Country:US
Practice Address - Phone:614-262-6772
Practice Address - Fax:614-533-0162
Is Sole Proprietor?:No
Enumeration Date:2019-06-24
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.025203363LG0600X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0361695Medicaid