Provider Demographics
NPI:1164480695
Name:BLACKBURN, JENNIFER ANN (MPT)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ANN
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:ANN
Other - Last Name:VIETH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:7575 5 MILE RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45230-4346
Mailing Address - Country:US
Mailing Address - Phone:513-233-4360
Mailing Address - Fax:513-233-4361
Practice Address - Street 1:7575 5 MILE RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45230-4346
Practice Address - Country:US
Practice Address - Phone:513-233-4360
Practice Address - Fax:513-233-4361
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT009214225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000390391OtherANTHEM
OH9429771OtherPHCS
OHP00325333OtherMEDICARE RAILROAD
OH2627170Medicaid
OH2627170Medicaid
OHVI4124613Medicare PIN