Provider Demographics
NPI:1790104362
Name:PATHADAN, JENNA (DO)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:PATHADAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 E APPLE ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45409-2902
Mailing Address - Country:US
Mailing Address - Phone:937-208-2004
Mailing Address - Fax:937-208-8828
Practice Address - Street 1:128 E APPLE ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-2902
Practice Address - Country:US
Practice Address - Phone:937-208-2004
Practice Address - Fax:937-208-8828
Is Sole Proprietor?:No
Enumeration Date:2014-04-10
Last Update Date:2017-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH390200000X
OH34013035207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program