Provider Demographics
NPI:1770044653
Name:PROKUP, JESSICA A (MD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:A
Last Name:PROKUP
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:700 ACKERMAN RD STE 2120
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1559
Mailing Address - Country:US
Mailing Address - Phone:614-366-9211
Mailing Address - Fax:614-293-1456
Practice Address - Street 1:2050 KENNY RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43221-3502
Practice Address - Country:US
Practice Address - Phone:614-366-9211
Practice Address - Fax:614-293-1456
Is Sole Proprietor?:No
Enumeration Date:2019-03-25
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH351473832080P0008X, 2081P0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPediatric Rehabilitation Medicine
No2080P0008XAllopathic & Osteopathic PhysiciansPediatricsNeurodevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0351783Medicaid