Provider Demographics
NPI:1649677188
Name:DIAMOND, JENNIFER LEANN
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LEANN
Last Name:DIAMOND
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:JENNIFER
Other - Middle Name:LEANN DIAMOND
Other - Last Name:BLACKBURN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:315 WOODSIDE DR
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:43031-1385
Mailing Address - Country:US
Mailing Address - Phone:859-625-8400
Mailing Address - Fax:
Practice Address - Street 1:315 WOODSIDE DR
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:OH
Practice Address - Zip Code:43031-1385
Practice Address - Country:US
Practice Address - Phone:859-625-8400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-27
Last Update Date:2014-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOT.008586171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor