Provider Demographics
NPI:1164761342
Name:PENN, JENNIFER RENEE' (NURSING ASSISTANT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RENEE'
Last Name:PENN
Suffix:
Gender:F
Credentials:NURSING ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1726 BLUFF PL APT 3C
Mailing Address - Street 2:
Mailing Address - City:WEST CARROLLTON
Mailing Address - State:OH
Mailing Address - Zip Code:45449-3173
Mailing Address - Country:US
Mailing Address - Phone:937-838-6232
Mailing Address - Fax:
Practice Address - Street 1:1726 BLUFF PL APT 3C
Practice Address - Street 2:
Practice Address - City:WEST CARROLLTON
Practice Address - State:OH
Practice Address - Zip Code:45449-3173
Practice Address - Country:US
Practice Address - Phone:937-838-6232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-07
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374U00000X, 376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No374U00000XNursing Service Related ProvidersHome Health Aide