Provider Demographics
NPI:1467673889
Name:SHAH, JENNIFER A (RN)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:SHAH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7340 BRANDTVISTA AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45424-3331
Mailing Address - Country:US
Mailing Address - Phone:937-602-1636
Mailing Address - Fax:937-528-2156
Practice Address - Street 1:6981 BRECKENWOOD DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45424-7326
Practice Address - Country:US
Practice Address - Phone:937-602-1636
Practice Address - Fax:937-528-2156
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN-231005163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2644133Medicaid