1962710103 NPI number — JENNIFER E LEIBOLD PA-C

Table of content: JENNIFER E LEIBOLD PA-C (NPI 1962710103)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962710103 NPI number — JENNIFER E LEIBOLD PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEIBOLD
Provider First Name:
JENNIFER
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962710103
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/30/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1010 WOODMAN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAYTON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45432-1400
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-424-2215
Provider Business Mailing Address Fax Number:
937-252-1224

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1010 WOODMAN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAYTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45432-1400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-424-2215
Provider Business Practice Location Address Fax Number:
937-252-3700
Provider Enumeration Date:
09/22/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  50001562 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363AM0700X , with the licence number: 50.001562 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0104799 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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