Basic Information
| Provider Information | |||||||||
| NPI: | 1285293142 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ADRIAN | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | DELAINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3533 SOUTHERN BLVD STE 2100 | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454291267 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373958556 | ||||||||
| FaxNumber: | 9373956376 | ||||||||
| Practice Location | |||||||||
| Address1: | 3535 SOUTHERN BLVD STE 2100 | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454291221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373958556 | ||||||||
| FaxNumber: | 9373956376 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2019 | ||||||||
| LastUpdateDate: | 11/13/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | APRN.CNOP.024796 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 0362039 | 05 | OH | MEDICAID |