Provider Demographics
NPI:1003057290
Name:GULLETTE, JESSICA DAWN (LPN)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:DAWN
Last Name:GULLETTE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:852 E MCCREIGHT AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45503-3438
Mailing Address - Country:US
Mailing Address - Phone:937-629-3771
Mailing Address - Fax:
Practice Address - Street 1:852 E MCCREIGHT AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-3438
Practice Address - Country:US
Practice Address - Phone:937-629-3771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-17
Last Update Date:2009-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN105893164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse