Basic Information
| Provider Information | |||||||||
| NPI: | 1548676778 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAUBERT | ||||||||
| FirstName: | JENNY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 449 | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457500449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403744500 | ||||||||
| FaxNumber: | 7403745887 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 MATTHEW ST | ||||||||
| Address2: | SUITE 303 | ||||||||
| City: | MARIETTA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457501644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403737828 | ||||||||
| FaxNumber: | 7403735898 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2014 | ||||||||
| LastUpdateDate: | 02/11/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 50.004096 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0110407 | 05 | OH | MEDICAID | P01401795 | 01 | OH | RAILROAD MEDICARE - MHCPI | OTHER |