Basic Information
| Provider Information | |||||||||
| NPI: | 1316146988 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LAINE | ||||||||
| FirstName: | JACLYN | ||||||||
| MiddleName: | MAUREEN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DRAKE | ||||||||
| OtherFirstName: | JACLYN | ||||||||
| OtherMiddleName: | MAUREEN | ||||||||
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| OtherCredential: | D.O, | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5400 FRANTZ RD | ||||||||
| Address2: | STE 250 | ||||||||
| City: | DUBLIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430164144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6145446155 | ||||||||
| FaxNumber: | 6145446370 | ||||||||
| Practice Location | |||||||||
| Address1: | 931 CHATHAM LN | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432212417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6145335500 | ||||||||
| FaxNumber: | 6145335593 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2007 | ||||||||
| LastUpdateDate: | 01/05/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 58 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | 2084N0400X | 34.010195 | OH | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 0061403 | 05 | OH | MEDICAID |