Provider Demographics
NPI:1528420650
Name:SUNDSTROM, JENNIFER (CNP)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:SUNDSTROM
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 PRESTIGE PL STE 550
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-6115
Mailing Address - Country:US
Mailing Address - Phone:937-762-1306
Mailing Address - Fax:937-522-7017
Practice Address - Street 1:3737 SOUTHERN BLVD STE 2000
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-1285
Practice Address - Country:US
Practice Address - Phone:937-228-4126
Practice Address - Fax:937-228-0247
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-28
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.273729363LG0600X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0165479Medicaid