Provider Demographics
NPI:1245647460
Name:WETZEL, JEANNE
Entity type:Individual
Prefix:
First Name:JEANNE
Middle Name:
Last Name:WETZEL
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 1:1154 IMMACULATE LN
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45255-4415
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5900 MEADOW CREEK DR
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:OH
Practice Address - Zip Code:45150-5641
Practice Address - Country:US
Practice Address - Phone:513-248-0655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-21
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH05350171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor