Provider Demographics
NPI:1942058144
Name:SMALL, JEFFREY ANTOINE
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:ANTOINE
Last Name:SMALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4042 GARDEN PARK DR
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43613-4043
Mailing Address - Country:US
Mailing Address - Phone:419-490-3711
Mailing Address - Fax:
Practice Address - Street 1:4042 GARDEN PARK DR
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43613-4043
Practice Address - Country:US
Practice Address - Phone:419-490-3711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-11
Last Update Date:2024-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSN3962503104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness