Individual
JACQUELINE S SHRIVER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
CRNP
Contact information
Practice address
1140 S KNOXVILLE AVE STE B, SAINT MARYS, OH 45885-2609
(419) 394-7314
(419) 394-7313
Mailing address
200 SAINT CLAIR AVE, SAINT MARYS, OH 45885-2400
(419) 300-1129
(419) 394-9575
Taxonomy
Speciality
Code
Description
License number
State
363LW0102X
Women's Health Nurse Practitioner
Primary
NP2122
OH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0105065
MEDICAID GROUP
OH
05
—
0742307
—
OH
01
—
1184652539
GROUP NPI
OH
01
—
34-1689161
GROUP TAX ID
OH
01
—
9934723
GROUP MEDICARE
OH
01
—
H561340
MEDICARE PTAN
OH
Enumeration date
08/19/2005
Last updated
04/19/2021
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