Provider Demographics
NPI:1871885020
Name:DETTY, JO ELLEN (LPN)
Entity type:Individual
Prefix:MRS
First Name:JO
Middle Name:ELLEN
Last Name:DETTY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1356 POLK HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-8933
Mailing Address - Country:US
Mailing Address - Phone:740-701-3110
Mailing Address - Fax:
Practice Address - Street 1:1356 POLK HOLLOW RD
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-8933
Practice Address - Country:US
Practice Address - Phone:740-701-3110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-06
Last Update Date:2011-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH143452164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse