Provider Demographics
NPI:1275510166
Name:WURST, JENNIFER LYNN (MD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LYNN
Last Name:WURST
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 1:3009 SMITH RD STE 350
Mailing Address - Street 2:
Mailing Address - City:FAIRLAWN
Mailing Address - State:OH
Mailing Address - Zip Code:44333-2670
Mailing Address - Country:US
Mailing Address - Phone:330-665-4488
Mailing Address - Fax:330-665-4489
Practice Address - Street 1:3009 SMITH RD STE 350
Practice Address - Street 2:
Practice Address - City:FAIRLAWN
Practice Address - State:OH
Practice Address - Zip Code:44333-2670
Practice Address - Country:US
Practice Address - Phone:330-665-4488
Practice Address - Fax:330-665-4489
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-08-2161207Q00000X
OH35082161W207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WU4112042Medicare ID - Type Unspecified
H89273Medicare UPIN