Provider Demographics
NPI:1225514706
Name:EBERLE, JESSICA SUE I
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:SUE
Last Name:EBERLE
Suffix:I
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8580 TOWNSHIP ROAD 1060
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44638-9723
Mailing Address - Country:US
Mailing Address - Phone:330-317-5777
Mailing Address - Fax:
Practice Address - Street 1:8580 TOWNSHIP ROAD 1060
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:OH
Practice Address - Zip Code:44638-9723
Practice Address - Country:US
Practice Address - Phone:330-317-5777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-17
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0297319Medicaid