Provider Demographics
NPI:1851398507
Name:GOULD, JENNIFER W (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:W
Last Name:GOULD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2500 W STRUB RD
Mailing Address - Street 2:SUITE 330
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870-5390
Mailing Address - Country:US
Mailing Address - Phone:419-626-6700
Mailing Address - Fax:419-626-6710
Practice Address - Street 1:2500 W STRUB RD
Practice Address - Street 2:SUITE 330
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-5390
Practice Address - Country:US
Practice Address - Phone:419-626-6700
Practice Address - Fax:419-626-6710
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35069468207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2353215Medicaid
OH070012084OtherRR MEDICARE
OH000000140612OtherANTHEM BLUE CROSS
OH2353215Medicaid
OHG73481Medicare UPIN
OH0848461Medicare ID - Type Unspecified