Provider Demographics
NPI:1821382482
Name:CARPENTER, JACQUELINE MARIE (DO)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:MARIE
Last Name:CARPENTER
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:PO BOX 635283
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-5283
Mailing Address - Country:US
Mailing Address - Phone:859-331-4665
Mailing Address - Fax:859-331-6370
Practice Address - Street 1:6105 1ST FINANCIAL DR
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:KY
Practice Address - Zip Code:41005-7892
Practice Address - Country:US
Practice Address - Phone:859-525-1846
Practice Address - Fax:859-647-3355
Is Sole Proprietor?:No
Enumeration Date:2011-06-01
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH58.003155207V00000X
KY03600207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0088573Medicaid
KY7100262850Medicaid
KYK105020Medicare PIN