Provider Demographics
NPI:1508898172
Name:TANDOC, JENNIFER M
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:TANDOC
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 1:36 PEMBERTON CV
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-5514
Mailing Address - Country:US
Mailing Address - Phone:731-394-1145
Mailing Address - Fax:
Practice Address - Street 1:6125 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415-3110
Practice Address - Country:US
Practice Address - Phone:731-394-1145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3003193363L00000X
OHAPRN.CNP.06859363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78003720Medicaid
KYP00847802OtherRAILROAD MEDICARE
KY500012750OtherRAILROAD MEDICARE
OH3088224Medicaid
OH3088224Medicaid
KY78003720Medicaid
KY0387427Medicare PIN