Basic Information
| Provider Information | |||||||||
| NPI: | 1437458114 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANDERS | ||||||||
| FirstName: | JENNA | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GINGERICH | ||||||||
| OtherFirstName: | JENNA | ||||||||
| OtherMiddleName: | NICOLE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 776879 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606776879 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025889490 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2051 CLEVIDENCE BLVD STE C | ||||||||
| Address2: | |||||||||
| City: | CLARKSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 471292278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122806623 | ||||||||
| FaxNumber: | 8122806627 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2011 | ||||||||
| LastUpdateDate: | 10/27/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 47001 | KY | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 01073708A | IN | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.