Provider Demographics
NPI:1790399756
Name:NICKERSON, JESSICA LYNN
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:NICKERSON
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 1:245 ELM ST
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:OH
Mailing Address - Zip Code:45101
Mailing Address - Country:US
Mailing Address - Phone:859-409-9201
Mailing Address - Fax:
Practice Address - Street 1:245 ELM ST
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:OH
Practice Address - Zip Code:45101
Practice Address - Country:US
Practice Address - Phone:859-409-9201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-06
Last Update Date:2020-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1106Medicaid