Basic Information
| Provider Information | |||||||||
| NPI: | 1184156358 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OTTERBACHER | ||||||||
| FirstName: | JENNIFER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 888 DAYTON ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | YELLOW SPGS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453871777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377677291 | ||||||||
| FaxNumber: | 9377671302 | ||||||||
| Practice Location | |||||||||
| Address1: | 888 DAYTON ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | YELLOW SPGS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453871777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377677291 | ||||||||
| FaxNumber: | 9377671302 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2017 | ||||||||
| LastUpdateDate: | 01/07/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 34.013646 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0407603 | 05 | OH | MEDICAID | FO8033653 | 01 | OH | DEA | OTHER |