Provider Demographics
NPI:1871993253
Name:EVANS, JEAN (STNA)
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 103
Mailing Address - Street 2:
Mailing Address - City:DONNELSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45319-0103
Mailing Address - Country:US
Mailing Address - Phone:937-369-8481
Mailing Address - Fax:
Practice Address - Street 1:110 N HARRISON RD
Practice Address - Street 2:
Practice Address - City:DONNELSVILLE
Practice Address - State:OH
Practice Address - Zip Code:45319-5018
Practice Address - Country:US
Practice Address - Phone:937-369-8481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-03
Last Update Date:2014-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2101693Medicaid