Provider Demographics
NPI:1477722056
Name:VANDEHATERT, JENIFER GEISS (PA)
Entity Type:Individual
Prefix:
First Name:JENIFER
Middle Name:GEISS
Last Name:VANDEHATERT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3180 KLEEMAN RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45211-1932
Mailing Address - Country:US
Mailing Address - Phone:513-260-5815
Mailing Address - Fax:
Practice Address - Street 1:3200 VINE ST
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45220-2213
Practice Address - Country:US
Practice Address - Phone:513-861-3100
Practice Address - Fax:513-475-6470
Is Sole Proprietor?:No
Enumeration Date:2008-02-27
Last Update Date:2009-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH002813363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000610048OtherANTHEM
OH0225920002OtherNSC
OHVAPA32961OtherMEDICARE