Provider Demographics
NPI:1245556117
Name:GERCKENS, JENNIFER SUSAN (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SUSAN
Last Name:GERCKENS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3921 WHITE OAK TRL
Mailing Address - Street 2:
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-4773
Mailing Address - Country:US
Mailing Address - Phone:763-402-2204
Mailing Address - Fax:
Practice Address - Street 1:23333 HARVARD RD
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-6232
Practice Address - Country:US
Practice Address - Phone:216-593-2208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-16
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.122325208100000X
MN58341208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation