Provider Demographics
NPI:1548504160
Name:ATWELL, JENNIFER MARIE (CERTIFIED PROVIDER)
Entity type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:MARIE
Last Name:ATWELL
Suffix:
Gender:F
Credentials:CERTIFIED PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 W RALEIGH AVE
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44907-1335
Mailing Address - Country:US
Mailing Address - Phone:567-241-3618
Mailing Address - Fax:419-775-5487
Practice Address - Street 1:85 W RALEIGH AVE
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44907-1335
Practice Address - Country:US
Practice Address - Phone:567-241-3618
Practice Address - Fax:419-775-5487
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-20
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2971324251C00000X, 251E00000X, 251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH7002406OtherOHIO DEPARTMENT OF DEVELOPMENTAL DISABILITIES CONTRACT NUMBER
OH2971324Medicaid