Provider Demographics
NPI:1790750446
Name:WELLS, JESSICA B (MD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:B
Last Name:WELLS
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:PO BOX 636643
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6643
Mailing Address - Country:US
Mailing Address - Phone:440-989-3801
Mailing Address - Fax:440-960-0264
Practice Address - Street 1:221 W 21ST ST
Practice Address - Street 2:STE 1
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44052-4754
Practice Address - Country:US
Practice Address - Phone:440-233-0138
Practice Address - Fax:440-233-1051
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35084345207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2472935Medicaid
OH3025372Medicaid
OH0236248Medicaid
OH9284951Medicare PIN
OH2472935Medicaid
OH4131291Medicare PIN
I05179Medicare UPIN