Provider Demographics
NPI:1154541118
Name:JANE BROERING AMMONS
Entity type:Organization
Organization Name:JANE BROERING AMMONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JANE
Authorized Official - Middle Name:A
Authorized Official - Last Name:BROERING AMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-866-8232
Mailing Address - Street 1:7429 INTERNATIONAL DR
Mailing Address - Street 2:#2
Mailing Address - City:HOLLAND
Mailing Address - State:OH
Mailing Address - Zip Code:43528
Mailing Address - Country:US
Mailing Address - Phone:419-866-8232
Mailing Address - Fax:419-866-8233
Practice Address - Street 1:7429 INTERNATIONAL DR
Practice Address - Street 2:#2
Practice Address - City:HOLLAND
Practice Address - State:OH
Practice Address - Zip Code:43528
Practice Address - Country:US
Practice Address - Phone:419-866-8232
Practice Address - Fax:419-866-8233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350644932084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0163255Medicaid
F91272Medicare UPIN
OH0163255Medicaid