Provider Demographics
NPI:1841498722
Name:CHUNG, JENNIFER (MD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:CHUNG
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 1:237 WILLIAM HOWARD TAFT RD
Mailing Address - Street 2:2ND FL, CBO2-3, ATTN: CREDENTIALING
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45219-2610
Mailing Address - Country:US
Mailing Address - Phone:513-792-7441
Mailing Address - Fax:513-791-4042
Practice Address - Street 1:9250 BLUE ASH RD
Practice Address - Street 2:
Practice Address - City:BLUE ASH
Practice Address - State:OH
Practice Address - Zip Code:45242-6822
Practice Address - Country:US
Practice Address - Phone:513-792-7445
Practice Address - Fax:513-791-4042
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2017-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY268967208100000X
KY46125208100000X
PA209100000X390200000X
OH35.121576208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH94269OtherMEDICAID
KY7100275100OtherMEDICAID
OH898704OtherANTHEM
KYK165100OtherMEDICARE
OHH249981OtherMEDICARE
OHCS1435100163OtherCARESOURCE
OH50077938OtherPASSPORT HEALTH
KY1062846OtherWELLCARE