Provider Demographics
NPI:1376867481
Name:BERTSCH, JESIAH LOU
Entity Type:Individual
Prefix:MRS
First Name:JESIAH
Middle Name:LOU
Last Name:BERTSCH
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:JESIAH
Other - Middle Name:LOU
Other - Last Name:JOLLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:PO BOX 636256
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6256
Mailing Address - Country:US
Mailing Address - Phone:513-245-3600
Mailing Address - Fax:513-245-3672
Practice Address - Street 1:2139 AUBURN AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-2906
Practice Address - Country:US
Practice Address - Phone:513-721-2221
Practice Address - Fax:513-345-6665
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-18
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.11377-NM367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3083792Medicaid