Provider Demographics
NPI:1144675489
Name:ANDERSON, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:462 TOWNSHIP ROAD 1101
Mailing Address - Street 2:
Mailing Address - City:NOVA
Mailing Address - State:OH
Mailing Address - Zip Code:44859-9737
Mailing Address - Country:US
Mailing Address - Phone:567-217-1980
Mailing Address - Fax:
Practice Address - Street 1:462 TOWNSHIP ROAD 1101
Practice Address - Street 2:
Practice Address - City:NOVA
Practice Address - State:OH
Practice Address - Zip Code:44859-9737
Practice Address - Country:US
Practice Address - Phone:567-217-1980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-24
Last Update Date:2016-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN114458164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse