Provider Demographics
NPI:1164816161
Name:PENNYWITT, JACQUELINE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:PENNYWITT
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 1:655 AFRICA RD
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43082-9808
Mailing Address - Country:US
Mailing Address - Phone:614-326-2672
Mailing Address - Fax:
Practice Address - Street 1:55 CLAIREDAN DR
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:OH
Practice Address - Zip Code:43065-8064
Practice Address - Country:US
Practice Address - Phone:614-888-8989
Practice Address - Fax:614-888-8968
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-27
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.130710208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty