Provider Demographics
NPI:1699379826
Name:RUDELL, JENNIFER MARIE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:RUDELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8142 ASCOT GLEN CT
Mailing Address - Street 2:
Mailing Address - City:LIBERTY TOWNSHIP
Mailing Address - State:OH
Mailing Address - Zip Code:45044-1204
Mailing Address - Country:US
Mailing Address - Phone:513-828-9989
Mailing Address - Fax:
Practice Address - Street 1:5981 FAR HILLS AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45429-2211
Practice Address - Country:US
Practice Address - Phone:937-438-5954
Practice Address - Fax:937-438-9505
Is Sole Proprietor?:No
Enumeration Date:2020-11-29
Last Update Date:2020-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03223700183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist