Healthcare Provider Details

I. General information

NPI: 1114345311
Provider Name (Legal Business Name): JENNA JUN POLDEMANN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JENNA MIN KYUM JUN M.D.

II. Dates (important events)

Enumeration Date: 04/03/2014
Last Update Date: 06/12/2024
Certification Date: 11/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 WYOMING ST
DAYTON OH
45409-2722
US

IV. Provider business mailing address

PO BOX 750243
DAYTON OH
45475-0243
US

V. Phone/Fax

Practice location:
  • Phone: 937-208-5642
  • Fax:
Mailing address:
  • Phone: 937-709-5051
  • Fax: 937-709-5050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number35.134735
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: