Provider Demographics
NPI:1326307208
Name:ROOT, JESSICA (LPM)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:ROOT
Suffix:
Gender:F
Credentials:LPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 W NORTH ST
Mailing Address - Street 2:
Mailing Address - City:PIQUA
Mailing Address - State:OH
Mailing Address - Zip Code:45356-2120
Mailing Address - Country:US
Mailing Address - Phone:937-418-3257
Mailing Address - Fax:
Practice Address - Street 1:625 W NORTH ST
Practice Address - Street 2:
Practice Address - City:PIQUA
Practice Address - State:OH
Practice Address - Zip Code:45356-2120
Practice Address - Country:US
Practice Address - Phone:937-418-3257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-11
Last Update Date:2012-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN148608164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse