1962786095 NPI number — MRS. JESSICA LYN EVANS CNM

Table of content: MRS. JESSICA LYN EVANS CNM (NPI 1962786095)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962786095 NPI number — MRS. JESSICA LYN EVANS CNM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EVANS
Provider First Name:
JESSICA
Provider Middle Name:
LYN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CNM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MOON
Provider Other First Name:
JESSICA
Provider Other Middle Name:
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1962786095
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/06/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 633448
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CINCINNATI
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45263-3448
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-853-4731
Provider Business Mailing Address Fax Number:
513-569-6117

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3219 CLIFTON AVE.,
Provider Second Line Business Practice Location Address:
STE. 210
Provider Business Practice Location Address City Name:
CINCINNATI
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45220-3041
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-751-5900
Provider Business Practice Location Address Fax Number:
513-487-4590
Provider Enumeration Date:
10/07/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367A00000X , with the licence number:  COA.12756 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0056363 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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