Healthcare Provider Details

I. General information

NPI: 1356162838
Provider Name (Legal Business Name): CATHERINE JEPSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CATHERINE THOMAS

II. Dates (important events)

Enumeration Date: 10/17/2024
Last Update Date: 10/24/2024
Certification Date: 10/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 E APPLE ST STE 5254
DAYTON OH
45409-2939
US

IV. Provider business mailing address

4370 LONGFELLOW AVE
DAYTON OH
45424-5949
US

V. Phone/Fax

Practice location:
  • Phone: 937-208-4200
  • Fax:
Mailing address:
  • Phone: 937-818-6739
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.008997RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: