Provider Demographics
NPI:1558879577
Name:BASFORD, JENNIFER RENEE (NP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RENEE
Last Name:BASFORD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1100 COMMERCE ST P.O. BOX 555
Mailing Address - Street 2:
Mailing Address - City:FORT RECOVERY
Mailing Address - State:OH
Mailing Address - Zip Code:45846
Mailing Address - Country:US
Mailing Address - Phone:419-375-5550
Mailing Address - Fax:
Practice Address - Street 1:1100 COMMERCE ST
Practice Address - Street 2:
Practice Address - City:FORT RECOVERY
Practice Address - State:OH
Practice Address - Zip Code:45846
Practice Address - Country:US
Practice Address - Phone:419-375-5550
Practice Address - Fax:419-375-5560
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-11
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71007732A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily