Provider Demographics
NPI:1124346879
Name:GASTENVELD, JENNIFER PETTIBONE (NP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:PETTIBONE
Last Name:GASTENVELD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ANN
Other - Last Name:PETTIBONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:237 WILLIAM HOWARD TAFT RD
Mailing Address - Street 2:2ND FLOOR, CBO 2-3
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45219-2610
Mailing Address - Country:US
Mailing Address - Phone:513-206-1180
Mailing Address - Fax:513-206-1183
Practice Address - Street 1:2123 AUBURN AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-2906
Practice Address - Country:US
Practice Address - Phone:513-206-1180
Practice Address - Fax:513-206-1183
Is Sole Proprietor?:No
Enumeration Date:2010-05-05
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH327169163W00000X, 363L00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3050764Medicaid
KY7100116680Medicaid
OHPENP35891Medicare PIN