Provider Demographics
NPI:1275730376
Name:MCCULLOUGH, JESSICA NICOLE (APRN, FNP, PMHNP)
Entity Type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:NICOLE
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:APRN, FNP, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2616 EDGEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-1560
Mailing Address - Country:US
Mailing Address - Phone:216-647-7449
Mailing Address - Fax:
Practice Address - Street 1:14100 CEDAR RD STE 390-2
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44121-3212
Practice Address - Country:US
Practice Address - Phone:216-905-0099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-02
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH312983163W00000X
OH14506363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0085765Medicaid
OH2573433OtherPROVIDER NUMBER
OH2573433OtherPROVIDER NUMBER