Provider Demographics
NPI:1588623391
Name:NITTLER, JESSICA RAE (MD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:RAE
Last Name:NITTLER
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:PO BOX 7687
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65205-7687
Mailing Address - Country:US
Mailing Address - Phone:573-882-2259
Mailing Address - Fax:
Practice Address - Street 1:1 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65212-0001
Practice Address - Country:US
Practice Address - Phone:573-882-1483
Practice Address - Fax:573-882-5370
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2009-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20040277942084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO152360113Medicare PIN