Healthcare Provider Details

I. General information

NPI: 1164816161
Provider Name (Legal Business Name): JACQUELINE PENNYWITT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2015
Last Update Date: 04/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 CLAIREDAN DR
POWELL OH
43065-8064
US

IV. Provider business mailing address

655 AFRICA RD
WESTERVILLE OH
43082-9808
US

V. Phone/Fax

Practice location:
  • Phone: 614-888-8989
  • Fax: 614-888-8968
Mailing address:
  • Phone: 614-326-2672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35.130710
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: