Healthcare Provider Details

I. General information

NPI: 1558879577
Provider Name (Legal Business Name): JENNIFER RENEE BASFORD NP.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JENNIFER MILLER

II. Dates (important events)

Enumeration Date: 01/11/2018
Last Update Date: 03/22/2023
Certification Date: 03/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 COMMERCE ST
FORT RECOVERY OH
45846
US

IV. Provider business mailing address

1100 COMMERCE ST P.O. BOX 555
FORT RECOVERY OH
45846
US

V. Phone/Fax

Practice location:
  • Phone: 419-375-5550
  • Fax: 419-375-5560
Mailing address:
  • Phone: 419-375-5550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71007732A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: