Healthcare Provider Details

I. General information

NPI: 1033669163
Provider Name (Legal Business Name): JENNIFER RODRIGUEZ FOSTER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2016
Last Update Date: 10/03/2022
Certification Date: 09/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 MIAMI VALLEY DR STE 160
CENTERVILLE OH
45459-4774
US

IV. Provider business mailing address

3170 KETTERING BLVD BLDG B
MORAINE OH
45439-1924
US

V. Phone/Fax

Practice location:
  • Phone: 937-312-1661
  • Fax: 937-312-1701
Mailing address:
  • Phone: 937-991-3188
  • Fax: 937-223-9811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC06155
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.006149
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: