=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760863195
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JASON RENNEKER
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/11/2015
-----------------------------------------------------
Last Update Date | 06/11/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5701 DELHI RD
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45233-1669
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-755-2078
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2168 W US HIGHWAY 22 AND 3
-----------------------------------------------------
City | MAINEVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45039-9267
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-755-2078
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | TY385314
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number | TY385314
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------