Provider Demographics
NPI:1417236050
Name:WELCH, JENNIFER SUE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SUE
Last Name:WELCH
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 1:15613 PINEVIEW DR
Mailing Address - Street 2:STE C
Mailing Address - City:EAST LIVERPOOL
Mailing Address - State:OH
Mailing Address - Zip Code:43920-9096
Mailing Address - Country:US
Mailing Address - Phone:330-382-1422
Mailing Address - Fax:330-382-1154
Practice Address - Street 1:15613 PINEVIEW DR
Practice Address - Street 2:STE C
Practice Address - City:EAST LIVERPOOL
Practice Address - State:OH
Practice Address - Zip Code:43920-9096
Practice Address - Country:US
Practice Address - Phone:330-382-1422
Practice Address - Fax:330-382-1154
Is Sole Proprietor?:No
Enumeration Date:2011-08-14
Last Update Date:2015-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH12307-NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner