Provider Demographics
NPI:1679679948
Name:HARTMAN, JESSYE
Entity Type:Individual
Prefix:
First Name:JESSYE
Middle Name:
Last Name:HARTMAN
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 1:10740 STATE ROUTE 295
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:OH
Mailing Address - Zip Code:43522-9620
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:138 E ELM ST
Practice Address - Street 2:
Practice Address - City:WAUSEON
Practice Address - State:OH
Practice Address - Zip Code:43567
Practice Address - Country:US
Practice Address - Phone:419-335-1919
Practice Address - Fax:419-335-1919
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH11390225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1679679948Medicaid