Healthcare Provider Details

I. General information

NPI: 1255807129
Provider Name (Legal Business Name): JENNIE KISER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2018
Last Update Date: 09/24/2021
Certification Date: 09/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

452 W MARKET ST
XENIA OH
45385-2815
US

IV. Provider business mailing address

452 W MARKET ST
XENIA OH
45385-2815
US

V. Phone/Fax

Practice location:
  • Phone: 937-376-8700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberS2101916TRNE
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: