Provider Demographics
NPI:1659365252
Name:JENRETTE, MARILYN SPRAGG (MD)
Entity Type:Individual
Prefix:DR
First Name:MARILYN
Middle Name:SPRAGG
Last Name:JENRETTE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3515 MASSILLON RD
Mailing Address - Street 2:STE 300
Mailing Address - City:UNIONTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44685-7854
Mailing Address - Country:US
Mailing Address - Phone:330-899-9350
Mailing Address - Fax:
Practice Address - Street 1:133 WILBUR DR NE
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-1641
Practice Address - Country:US
Practice Address - Phone:330-494-6012
Practice Address - Fax:330-494-3880
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-09
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35048766207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0513680Medicaid
A15351Medicare UPIN