Provider Demographics
NPI:1548676778
Name:DAUBERT, JENNY M (PA-C)
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:M
Last Name:DAUBERT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 449
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-0449
Mailing Address - Country:US
Mailing Address - Phone:740-374-4500
Mailing Address - Fax:740-374-5887
Practice Address - Street 1:400 MATTHEW ST
Practice Address - Street 2:SUITE 303
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-1644
Practice Address - Country:US
Practice Address - Phone:740-373-7828
Practice Address - Fax:740-373-5898
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-09
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.004096363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0110407Medicaid
OHP01401795OtherRAILROAD MEDICARE - MHCPI
OHH396271Medicare PIN
OHH396270Medicare PIN