Provider Demographics
NPI:1184983439
Name:VAN HATTEM, JENNIFER L (LPN)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:L
Last Name:VAN HATTEM
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:L
Other - Last Name:RODDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:226 WHITE ST
Mailing Address - Street 2:
Mailing Address - City:CLYDE
Mailing Address - State:OH
Mailing Address - Zip Code:43410-1930
Mailing Address - Country:US
Mailing Address - Phone:419-650-0392
Mailing Address - Fax:
Practice Address - Street 1:226 WHITE ST
Practice Address - Street 2:
Practice Address - City:CLYDE
Practice Address - State:OH
Practice Address - Zip Code:43410-1930
Practice Address - Country:US
Practice Address - Phone:419-650-0392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-08
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN121705-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse