Provider Demographics
NPI:1619571999
Name:CAVANAUGH, JESSE
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:CAVANAUGH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:814 EASTLAND DR
Mailing Address - Street 2:
Mailing Address - City:VILLA HILLS
Mailing Address - State:KY
Mailing Address - Zip Code:41017-1011
Mailing Address - Country:US
Mailing Address - Phone:937-818-1988
Mailing Address - Fax:
Practice Address - Street 1:3516 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:ERLANGER
Practice Address - State:KY
Practice Address - Zip Code:41018-1804
Practice Address - Country:US
Practice Address - Phone:859-331-6878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-26
Last Update Date:2020-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY019636183500000X
OH03236972183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist