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General NPI Number Information
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NPI Number | 1033628268
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Entity Type | Individual
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Provider Name | JENNIFER TERESA SPRAGUE
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Gender | Female
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Dates
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Enumeration Date | 09/20/2017
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Last Update Date | 09/16/2021
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Provider Practice Location Address
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Address Line | 10506 MONTGOMERY RD STE 200A
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City | MONTGOMERY
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State | OH
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Zip | 45242-4400
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Country | US
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Telephone | 513-865-2227
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Fax | 513-865-5552
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Provider Business Mailing Address
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Address Line | 2300 CHAMBER CENTER DR
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City | LAKESIDE PARK
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State | KY
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Zip | 41017-1686
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Country | US
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Telephone | 859-301-4723
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Fax | 859-301-4724
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | TC639
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License Number State | KY
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 50.005482RX
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License Number State | OH
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