Provider Demographics
NPI:1184184582
Name:WORLUMARTI, JESSE
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:WORLUMARTI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 VANIMAN AVE
Mailing Address - Street 2:
Mailing Address - City:TROTWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45426-2529
Mailing Address - Country:US
Mailing Address - Phone:732-762-5834
Mailing Address - Fax:
Practice Address - Street 1:413 VANIMAN AVE
Practice Address - Street 2:
Practice Address - City:TROTWOOD
Practice Address - State:OH
Practice Address - Zip Code:45426-2529
Practice Address - Country:US
Practice Address - Phone:732-762-5834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-21
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH400795720808376K00000X
OH5712447374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH5712447Medicaid
OH3154063Medicaid