Healthcare Provider Details

I. General information

NPI: 1144675489
Provider Name (Legal Business Name): JENNIFER ANDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2016
Last Update Date: 04/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

462 TOWNSHIP ROAD 1101
NOVA OH
44859-9737
US

IV. Provider business mailing address

462 TOWNSHIP ROAD 1101
NOVA OH
44859-9737
US

V. Phone/Fax

Practice location:
  • Phone: 567-217-1980
  • Fax:
Mailing address:
  • Phone: 567-217-1980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN114458
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: