Basic Information
| Provider Information | |||||||||
| NPI: | 1396802096 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COUNTRYMAN | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 S EDWIN C MOSES BLVD | ||||||||
| Address2: | EAST BUILDING, 4TH FLOOR | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454081424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372768333 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 601 S EDWIN C MOSES BLVD | ||||||||
| Address2: | EAST BUILDING, 4TH FLOOR | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454081424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372768333 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 2084P0800X | 35-07-3384-C | OH | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.