Provider Demographics
NPI:1487647053
Name:JESICK, ANN R (MD)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:R
Last Name:JESICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANA
Mailing Address - State:PA
Mailing Address - Zip Code:15701-2776
Mailing Address - Country:US
Mailing Address - Phone:724-349-7388
Mailing Address - Fax:724-463-7072
Practice Address - Street 1:15 S 8TH ST
Practice Address - Street 2:
Practice Address - City:INDIANA
Practice Address - State:PA
Practice Address - Zip Code:15701-2776
Practice Address - Country:US
Practice Address - Phone:724-349-7388
Practice Address - Fax:724-463-7072
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-29
Last Update Date:2010-01-13
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-04-04
Provider Licenses
StateLicense IDTaxonomies
PAMD036779207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1132167Medicaid
162082OtherBS
7853184OtherAETNA
162082OtherBS
B40380Medicare UPIN