Provider Demographics
NPI:1548269657
Name:MCLELLAN, JENNIFER M (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:MCLELLAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:935 STATE ROUTE 28
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:OH
Mailing Address - Zip Code:45150-1957
Mailing Address - Country:US
Mailing Address - Phone:513-831-5955
Mailing Address - Fax:513-831-5985
Practice Address - Street 1:935 STATE ROUTE 28
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:OH
Practice Address - Zip Code:45150-1957
Practice Address - Country:US
Practice Address - Phone:513-831-8555
Practice Address - Fax:513-831-8685
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35075113M207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2208677Medicaid
OHP00296014Medicare PIN
OH2208677Medicaid
OHH25362Medicare UPIN