Healthcare Provider Details

I. General information

NPI: 1437458114
Provider Name (Legal Business Name): JENNA NICOLE SANDERS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNA NICOLE GINGERICH

II. Dates (important events)

Enumeration Date: 03/21/2011
Last Update Date: 02/09/2023
Certification Date: 02/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2051 CLEVIDENCE BLVD STE C
CLARKSVILLE IN
47129-2278
US

IV. Provider business mailing address

PO BOX 776879
CHICAGO IL
60677-6879
US

V. Phone/Fax

Practice location:
  • Phone: 812-280-6623
  • Fax: 812-280-6627
Mailing address:
  • Phone: 502-588-9490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number47001
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01073708A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: