Provider Demographics
NPI:1679511976
Name:MADDEN, JESSICA W (MD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:W
Last Name:MADDEN
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 1:31731 LAKE SHORE BLVD
Mailing Address - Street 2:
Mailing Address - City:WILLOWICK
Mailing Address - State:OH
Mailing Address - Zip Code:44095-3529
Mailing Address - Country:US
Mailing Address - Phone:216-313-2016
Mailing Address - Fax:
Practice Address - Street 1:31731 LAKE SHORE BLVD
Practice Address - Street 2:
Practice Address - City:WILLOWICK
Practice Address - State:OH
Practice Address - Zip Code:44095-3529
Practice Address - Country:US
Practice Address - Phone:216-313-2016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.0876752080N0001X
WI527482080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1679511976Medicaid
WI52748OtherWI LICENSE
OH35.087675OtherSTATE MEDICAL LICENSE