Basic Information
| Provider Information | |||||||||
| NPI: | 1629658026 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POWELL | ||||||||
| FirstName: | JENNA | ||||||||
| MiddleName: | RENEE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7663 HUNTINGTON DR | ||||||||
| Address2: | |||||||||
| City: | BOARDMAN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 445124047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307707061 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2401 BELMONT AVE | ||||||||
| Address2: | |||||||||
| City: | YOUNGSTOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 445052405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307431015 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2021 | ||||||||
| LastUpdateDate: | 04/20/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | F11200480 | OH | N | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | APRN.CNP.0028765 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 0439688 | 05 | OH | MEDICAID |