Provider Demographics
NPI:1184156358
Name:OTTERBACHER, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:OTTERBACHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:888 DAYTON ST STE 200
Mailing Address - Street 2:
Mailing Address - City:YELLOW SPGS
Mailing Address - State:OH
Mailing Address - Zip Code:45387-1777
Mailing Address - Country:US
Mailing Address - Phone:937-767-7291
Mailing Address - Fax:937-767-1302
Practice Address - Street 1:888 DAYTON ST STE 200
Practice Address - Street 2:
Practice Address - City:YELLOW SPGS
Practice Address - State:OH
Practice Address - Zip Code:45387-1777
Practice Address - Country:US
Practice Address - Phone:937-767-7291
Practice Address - Fax:937-767-1302
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.013646207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0407603Medicaid
OHFO8033653OtherDEA