Provider Demographics
NPI:1033628268
Name:SPRAGUE, JENNIFER TERESA
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:TERESA
Last Name:SPRAGUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 CHAMBER CENTER DR
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE PARK
Mailing Address - State:KY
Mailing Address - Zip Code:41017-1686
Mailing Address - Country:US
Mailing Address - Phone:859-301-4723
Mailing Address - Fax:859-301-4724
Practice Address - Street 1:10506 MONTGOMERY RD STE 200A
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:OH
Practice Address - Zip Code:45242-4400
Practice Address - Country:US
Practice Address - Phone:513-865-2227
Practice Address - Fax:513-865-5552
Is Sole Proprietor?:No
Enumeration Date:2017-09-20
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC639363A00000X
OH50.005482RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2565399Medicaid