Provider Demographics
NPI:1689646721
Name:JAHNKE, MICHELLE ALYCE (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ALYCE
Last Name:JAHNKE
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 1:6693 N CHESTNUT ST STE 125A
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-3900
Mailing Address - Country:US
Mailing Address - Phone:330-296-2879
Mailing Address - Fax:
Practice Address - Street 1:6693 N CHESTNUT ST STE 125A
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-3900
Practice Address - Country:US
Practice Address - Phone:330-296-2879
Practice Address - Fax:330-296-4656
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-03
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-07-3098J207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9349181Medicare PIN
OHH11611Medicare UPIN