Provider Demographics
NPI:1619316056
Name:JODREY, KIMBERLEY DAWN (CNP)
Entity Type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:DAWN
Last Name:JODREY
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17862 STATE ROUTE 247
Mailing Address - Street 2:
Mailing Address - City:SEAMAN
Mailing Address - State:OH
Mailing Address - Zip Code:45679
Mailing Address - Country:US
Mailing Address - Phone:937-695-0748
Mailing Address - Fax:937-695-1260
Practice Address - Street 1:17862 STATE ROUTE 247
Practice Address - Street 2:
Practice Address - City:SEAMAN
Practice Address - State:OH
Practice Address - Zip Code:45679
Practice Address - Country:US
Practice Address - Phone:937-695-0748
Practice Address - Fax:937-695-1260
Is Sole Proprietor?:No
Enumeration Date:2013-06-19
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.14613-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0086090Medicaid
KY7100339380Medicaid
KY7100339380Medicaid