Provider Demographics
NPI:1689950776
Name:HARTSON, JESSICA BOLDT
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:BOLDT
Last Name:HARTSON
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 1:218 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PIQUA
Mailing Address - State:OH
Mailing Address - Zip Code:45356-4038
Mailing Address - Country:US
Mailing Address - Phone:937-451-7308
Mailing Address - Fax:
Practice Address - Street 1:218 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PIQUA
Practice Address - State:OH
Practice Address - Zip Code:45356-4038
Practice Address - Country:US
Practice Address - Phone:937-451-7308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-02
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH141872172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker