Provider Demographics
NPI:1356698948
Name:EBY, JENNIFER E (PA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:E
Last Name:EBY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:E
Other - Last Name:BAMBECK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:4881 SUGAR MAPLE DR
Mailing Address - Street 2:
Mailing Address - City:WPAFB
Mailing Address - State:OH
Mailing Address - Zip Code:45433-5529
Mailing Address - Country:US
Mailing Address - Phone:937-257-1274
Mailing Address - Fax:937-656-1235
Practice Address - Street 1:4881 SUGAR MAPLE DR
Practice Address - Street 2:
Practice Address - City:WPAFB
Practice Address - State:OH
Practice Address - Zip Code:45433-5529
Practice Address - Country:US
Practice Address - Phone:937-257-1274
Practice Address - Fax:937-656-1235
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-14
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0078477Medicaid
OH50003574OtherOHIO LICENSE
OH50003574OtherOHIO LICENSE