Healthcare Provider Details

I. General information

NPI: 1962710103
Provider Name (Legal Business Name): JENNIFER E LEIBOLD PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2010
Last Update Date: 03/05/2026
Certification Date: 03/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5491 FAR HILLS AVE
DAYTON OH
45429-2325
US

IV. Provider business mailing address

1430 OAK CT STE 100
BEAVERCREEK OH
45430-1064
US

V. Phone/Fax

Practice location:
  • Phone: 937-436-5763
  • Fax:
Mailing address:
  • Phone: 937-404-1101
  • Fax: 937-404-1210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50001562
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number50.001562
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: