Provider Demographics
NPI:1023194248
Name:CONLON, JENNIFER MARIE (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:CONLON
Suffix:
Gender:F
Credentials:MD
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 933432
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44193-0039
Mailing Address - Country:US
Mailing Address - Phone:937-641-5072
Mailing Address - Fax:
Practice Address - Street 1:5450 FAR HILLS AVE STE 110
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-2346
Practice Address - Country:US
Practice Address - Phone:937-436-2866
Practice Address - Fax:937-436-1468
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.065320208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0114414Medicaid
0114414OtherBUR CHILDREN W MED HANDIC
4644133OtherAETNA
000000339085OtherBLUE CROSS BLUE SHIELD
1333851OtherUNITED HEALTHCARE
311627276034OtherCARESOURCE