Basic Information
| Provider Information | |||||||||
| NPI: | 1497806897 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NIESEN | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | FERN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SIMMONS | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | FERN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1005 BELLEFONTAINE AVE | ||||||||
| Address2: | SUITE 175 | ||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458042851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192272727 | ||||||||
| FaxNumber: | 4192272737 | ||||||||
| Practice Location | |||||||||
| Address1: | 1005 BELLEFONTAINE AVE | ||||||||
| Address2: | SUITE 175 | ||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458042851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192272727 | ||||||||
| FaxNumber: | 4192272737 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2007 | ||||||||
| LastUpdateDate: | 11/07/2018 | ||||||||
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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 | 207V00000X | 9005 | OH | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 2774387 | 05 | OH | MEDICAID |