Provider Demographics
NPI:1497445118
Name:MANDEVILLE, JESSICA JERA (APRN)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:JERA
Last Name:MANDEVILLE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:329 N WEST ST
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45801-4331
Mailing Address - Country:US
Mailing Address - Phone:419-221-3072
Mailing Address - Fax:
Practice Address - Street 1:111 W ESPY ST
Practice Address - Street 2:
Practice Address - City:KENTON
Practice Address - State:OH
Practice Address - Zip Code:43326-2117
Practice Address - Country:US
Practice Address - Phone:419-679-5994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-08
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0033731363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily