Basic Information
| Provider Information | |||||||||
| NPI: | 1659365252 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JENRETTE | ||||||||
| FirstName: | MARILYN | ||||||||
| MiddleName: | SPRAGG | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3515 MASSILLON RD | ||||||||
| Address2: | STE 300 | ||||||||
| City: | UNIONTOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446857854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308999350 | ||||||||
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| Practice Location | |||||||||
| Address1: | 133 WILBUR DR NE | ||||||||
| Address2: | |||||||||
| City: | NORTH CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447201641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304946012 | ||||||||
| FaxNumber: | 3304943880 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2005 | ||||||||
| LastUpdateDate: | 06/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35048766 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0513680 | 05 | OH | MEDICAID |