Provider Demographics
NPI:1295724946
Name:KEEHBAUCH, JENNIFER (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:KEEHBAUCH
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 1:133 BENMORE DRIVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-4143
Mailing Address - Country:US
Mailing Address - Phone:407-646-7070
Mailing Address - Fax:407-646-7757
Practice Address - Street 1:133 BENMORE DRIVE
Practice Address - Street 2:SUITE 200
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-4143
Practice Address - Country:US
Practice Address - Phone:407-646-7070
Practice Address - Fax:407-646-7757
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 0075471207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL257129300Medicaid
FL257129300Medicaid
F 92186Medicare UPIN