Healthcare Provider Details

I. General information

NPI: 1659365252
Provider Name (Legal Business Name): MARILYN SPRAGG JENRETTE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 06/23/2020
Certification Date: 06/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 WILBUR DR NE
NORTH CANTON OH
44720-1641
US

IV. Provider business mailing address

3515 MASSILLON RD STE 300
UNIONTOWN OH
44685-7854
US

V. Phone/Fax

Practice location:
  • Phone: 330-494-6012
  • Fax: 330-494-3880
Mailing address:
  • Phone: 330-899-9350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35048766
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: