Provider Demographics
NPI:1609494350
Name:FANNIN, JESSICA LYNNE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNNE
Last Name:FANNIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9482 WEDGEWOOD BLVD STE 50
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:OH
Mailing Address - Zip Code:43065-0268
Mailing Address - Country:US
Mailing Address - Phone:614-444-2273
Mailing Address - Fax:
Practice Address - Street 1:9482 WEDGEWOOD BLVD STE 50
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:OH
Practice Address - Zip Code:43065-0268
Practice Address - Country:US
Practice Address - Phone:614-444-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-09
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator