Provider Demographics
NPI:1841407293
Name:DERWENT, JESSICA LYNN (STNA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:DERWENT
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1909 ST. RT. 257 N
Mailing Address - Street 2:
Mailing Address - City:OSTRANDER
Mailing Address - State:OH
Mailing Address - Zip Code:43061-9721
Mailing Address - Country:US
Mailing Address - Phone:740-272-8099
Mailing Address - Fax:
Practice Address - Street 1:109 MUIRWOOD VILLAGE DR
Practice Address - Street 2:
Practice Address - City:DELAWARE
Practice Address - State:OH
Practice Address - Zip Code:43015-1082
Practice Address - Country:US
Practice Address - Phone:740-369-2213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2663550374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide