Provider Demographics
NPI:1609995273
Name:WHITE, JENNIFER NICOLE (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:NICOLE
Last Name:WHITE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:NICOLE
Other - Last Name:MANNING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11140 MONTGOMERY ROAD
Mailing Address - Street 2:SUITE 2500
Mailing Address - City:MONTGOMERY
Mailing Address - State:OH
Mailing Address - Zip Code:45249
Mailing Address - Country:US
Mailing Address - Phone:513-561-7809
Mailing Address - Fax:513-272-4121
Practice Address - Street 1:11140 MONTGOMERY ROAD
Practice Address - Street 2:SUITE 2500
Practice Address - City:MONTGOMERY
Practice Address - State:OH
Practice Address - Zip Code:45249
Practice Address - Country:US
Practice Address - Phone:513-561-7809
Practice Address - Fax:513-272-4121
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35091769207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2861121Medicaid
KY7100103790Medicaid
OH2861121Medicaid