MEDICARE: MOLLY E ENNIS PA

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	363A00000X	Physician Assistant	50.004354RX	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1881085306
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MOLLY E ENNIS PA

Provider Business Mailing Address
First Line	:	4600 MCAULEY PL STE 600
Second Line	:
City	:	BLUE ASH
State	:	OH
Zip	:	45242-4778
Country	:	US
Telephone Number	:	877-692-7780
Fax Number	:

Provider Business Practice Location Address
First Line	:	47185 COOPER FOSTER PARK RD
Second Line	:
City	:	AMHERST
State	:	OH
Zip	:	44001-3307
Country	:	US
Telephone Number	:	440-960-3954
Fax Number	:	440-960-3956

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

Provider Enumeration Date	:	02/06/2015
Last Update Date	:	07/07/2025

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1760485759 — DR. ANNE ELIZABETH JACKO D.D.S.
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Directions to “ MOLLY E ENNIS PA” Practice Location

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