Provider Demographics
NPI:1033461264
Name:DEWITT, JENNIFER LOUISE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LOUISE
Last Name:DEWITT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LOUISE
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:STNA
Mailing Address - Street 1:1046 TOWNSHIP ROAD 2826
Mailing Address - Street 2:
Mailing Address - City:PERRYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44864-9753
Mailing Address - Country:US
Mailing Address - Phone:234-525-0456
Mailing Address - Fax:
Practice Address - Street 1:1046 TOWNSHIP ROAD 2826
Practice Address - Street 2:
Practice Address - City:PERRYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:44864-9753
Practice Address - Country:US
Practice Address - Phone:234-525-0456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-11
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401380110412376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide