Provider Demographics
NPI:1457369696
Name:DANIELS, JENNIFER MARIE (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:DANIELS
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 1:30 WARDER ST
Mailing Address - Street 2:SUITE 220
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45504-2500
Mailing Address - Country:US
Mailing Address - Phone:937-399-7021
Mailing Address - Fax:937-399-0697
Practice Address - Street 1:30 WARDER ST
Practice Address - Street 2:SUITE 220
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45504-2500
Practice Address - Country:US
Practice Address - Phone:937-399-7021
Practice Address - Fax:937-399-0697
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH35-084309208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2484002Medicaid
I12282Medicare UPIN
OHDA4139001Medicare ID - Type Unspecified