Provider Demographics
NPI:1548858939
Name:DEFOREST, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:DEFOREST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:GRILLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11447 VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:THE PLAINS
Mailing Address - State:OH
Mailing Address - Zip Code:45780-1428
Mailing Address - Country:US
Mailing Address - Phone:740-707-1691
Mailing Address - Fax:
Practice Address - Street 1:3 COVENTRY LN
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701-3717
Practice Address - Country:US
Practice Address - Phone:740-707-1691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-02
Last Update Date:2021-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
320900000X
OH8701195320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0427093Medicaid