Provider Demographics
NPI:1275510166
Name:WURST, JENNIFER LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LYNN
Last Name:WURST
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:12744 STATE RD
Mailing Address - Street 2:
Mailing Address - City:NORTH ROYALTON
Mailing Address - State:OH
Mailing Address - Zip Code:44133-3910
Mailing Address - Country:US
Mailing Address - Phone:440-582-1484
Mailing Address - Fax:440-582-1594
Practice Address - Street 1:303 E ROYALTON RD STE 101
Practice Address - Street 2:
Practice Address - City:BROADVIEW HTS
Practice Address - State:OH
Practice Address - Zip Code:44147-2591
Practice Address - Country:US
Practice Address - Phone:440-743-4740
Practice Address - Fax:440-743-4741
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35082161W207Q00000X
OH35-08-2161207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WU4112042Medicare ID - Type Unspecified
H89273Medicare UPIN