Provider Demographics
NPI:1861659039
Name:MALEK, JENNIFER D (CNS,BC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:D
Last Name:MALEK
Suffix:
Gender:F
Credentials:CNS,BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3535 PENTAGON BLVD STE 230
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45431-1705
Mailing Address - Country:US
Mailing Address - Phone:855-500-2873
Mailing Address - Fax:937-281-3913
Practice Address - Street 1:5350 LAMME RD
Practice Address - Street 2:
Practice Address - City:MORAINE
Practice Address - State:OH
Practice Address - Zip Code:45439-3215
Practice Address - Country:US
Practice Address - Phone:937-534-4651
Practice Address - Fax:937-534-4669
Is Sole Proprietor?:No
Enumeration Date:2008-05-16
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNS01078364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0052850Medicaid
OHH022460Medicare PIN