Provider Demographics
NPI:1871845313
Name:OTTERBACH, JENNIFER RENEE (HM1 IDC)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:RENEE
Last Name:OTTERBACH
Suffix:
Gender:F
Credentials:HM1 IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 HAILEY CT
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-3137
Mailing Address - Country:US
Mailing Address - Phone:904-314-2423
Mailing Address - Fax:
Practice Address - Street 1:4000 HAILEY CT
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23321-3137
Practice Address - Country:US
Practice Address - Phone:904-314-2423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-08
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman