Provider Demographics
NPI:1437458114
Name:SANDERS, JENNA NICOLE (MD)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:NICOLE
Last Name:SANDERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:NICOLE
Other - Last Name:GINGERICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 776879
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6879
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:
Practice Address - Street 1:2051 CLEVIDENCE BLVD STE C
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47129-2278
Practice Address - Country:US
Practice Address - Phone:812-280-6623
Practice Address - Fax:812-280-6627
Is Sole Proprietor?:No
Enumeration Date:2011-03-21
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY47001208000000X
IN01073708A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201249990Medicaid
KY7100212230Medicaid
KYK298210OtherMEDICARE