Provider Demographics
NPI:1013298298
Name:DEVRIES, JENNIFER (NP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:DEVRIES
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:745 HASKINS RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402-1637
Mailing Address - Country:US
Mailing Address - Phone:419-353-7069
Mailing Address - Fax:419-353-7076
Practice Address - Street 1:1215 RIDGEWOOD DR
Practice Address - Street 2:SUITE B
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402-2690
Practice Address - Country:US
Practice Address - Phone:419-352-9071
Practice Address - Fax:419-352-9073
Is Sole Proprietor?:No
Enumeration Date:2011-09-01
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA12594-NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPENDINGMedicaid
OHH023600Medicare PIN