Provider Demographics
NPI:1497806897
Name:NIESEN, JENNIFER FERN (DO)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:FERN
Last Name:NIESEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:FERN
Other - Last Name:SIMMONS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1005 BELLEFONTAINE AVE
Mailing Address - Street 2:SUITE 175
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45804-2851
Mailing Address - Country:US
Mailing Address - Phone:419-227-2727
Mailing Address - Fax:419-227-2737
Practice Address - Street 1:1005 BELLEFONTAINE AVE
Practice Address - Street 2:SUITE 175
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45804-2851
Practice Address - Country:US
Practice Address - Phone:419-227-2727
Practice Address - Fax:419-227-2737
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH9005207V00000X
MI5101015847207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2774387Medicaid