Provider Demographics
NPI:1295024131
Name:MITTLESTEAD, JENNIFER ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:ANN
Last Name:MITTLESTEAD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:ANN
Other - Last Name:SHIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5701 FAR HILLS AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45429-2207
Mailing Address - Country:US
Mailing Address - Phone:937-435-6222
Mailing Address - Fax:
Practice Address - Street 1:5701 FAR HILLS AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45429-2207
Practice Address - Country:US
Practice Address - Phone:937-435-6222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-31
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.125512207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2147224OtherGROUP MEDICAID
OH9271701OtherGROUP MEDICARE