Provider Demographics
NPI:1699199349
Name:FARRIS, JENNIFER (MOTR/L)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:FARRIS
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:196 WORTHINGTON DR
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45327-8354
Mailing Address - Country:US
Mailing Address - Phone:937-895-4044
Mailing Address - Fax:
Practice Address - Street 1:540 PARK AVE
Practice Address - Street 2:
Practice Address - City:MIAMISBURG
Practice Address - State:OH
Practice Address - Zip Code:45342-2854
Practice Address - Country:US
Practice Address - Phone:937-866-4347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-14
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH006118174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist