MEDICARE: MICHELLE ALYCE JAHNKE MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	35-07-3098J	OH

General Provider Information

NPI Number	:	1689646721
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE ALYCE JAHNKE MD

Provider Business Mailing Address
First Line	:	6693 N CHESTNUT ST STE 125A
Second Line	:
City	:	RAVENNA
State	:	OH
Zip	:	44266-3900
Country	:	US
Telephone Number	:	330-296-2879
Fax Number	:

Provider Business Practice Location Address
First Line	:	6693 N CHESTNUT ST STE 125A
Second Line	:
City	:	RAVENNA
State	:	OH
Zip	:	44266-3900
Country	:	US
Telephone Number	:	330-296-2879
Fax Number	:	330-296-4656

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/03/2006
Last Update Date	:	10/22/2008

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