Basic Information
| Provider Information | |||||||||
| NPI: | 1255715231 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HASELMAN | ||||||||
| FirstName: | JENNIFER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5300 HARROUN RD | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | SYLVANIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435602182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198241100 | ||||||||
| FaxNumber: | 4198241771 | ||||||||
| Practice Location | |||||||||
| Address1: | 5300 HARROUN RD | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | SYLVANIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435602182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198241100 | ||||||||
| FaxNumber: | 4198241771 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2015 | ||||||||
| LastUpdateDate: | 10/30/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | COA17566NP | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 0140351 | 05 | OH | MEDICAID |