Basic Information
Provider Information | |||||||||
NPI: | 1023071388 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KIBBEY | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | LYNN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BROWN | ||||||||
OtherFirstName: | JENNIFER | ||||||||
OtherMiddleName: | LYNN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 70 S CLEVELAND AVE | ||||||||
Address2: |   | ||||||||
City: | WESTERVILLE | ||||||||
State: | OH | ||||||||
PostalCode: | 430811397 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6148906555 | ||||||||
FaxNumber: | 6148238881 | ||||||||
Practice Location | |||||||||
Address1: | 5040 FOREST DR | ||||||||
Address2: |   | ||||||||
City: | NEW ALBANY | ||||||||
State: | OH | ||||||||
PostalCode: | 430548167 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6148906555 | ||||||||
FaxNumber: | 6148911484 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/08/2006 | ||||||||
LastUpdateDate: | 10/28/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 50.001845 | OH | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AM0700X | 50.001845 | OH | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
ID | Type | State | Issuer | Description | 1023071388 | 01 | OH | NPI | OTHER |