Basic Information
| Provider Information | |||||||||
| NPI: | 1861659039 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALEK | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | CNS,BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3535 PENTAGON BLVD STE 230 | ||||||||
| Address2: | |||||||||
| City: | BEAVERCREEK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454311705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8555002873 | ||||||||
| FaxNumber: | 9372813913 | ||||||||
| Practice Location | |||||||||
| Address1: | 5350 LAMME RD | ||||||||
| Address2: | |||||||||
| City: | MORAINE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454393215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9375344651 | ||||||||
| FaxNumber: | 9375344669 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2008 | ||||||||
| LastUpdateDate: | 01/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364S00000X | NS01078 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist |
ID Information
| ID | Type | State | Issuer | Description | 0052850 | 05 | OH | MEDICAID |