=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699199349
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER FARRIS MOTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2014
-----------------------------------------------------
Last Update Date | 02/14/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 540 PARK AVE
-----------------------------------------------------
City | MIAMISBURG
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45342-2854
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-866-4347
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 196 WORTHINGTON DR
-----------------------------------------------------
City | GERMANTOWN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45327-8354
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-895-4044
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 006118
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------