Provider Demographics
NPI:1891112751
Name:OEHLKE, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:OEHLKE
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 1:112 SOLLER HEIGHTS RD
Mailing Address - Street 2:
Mailing Address - City:GHENT
Mailing Address - State:NY
Mailing Address - Zip Code:12075-3003
Mailing Address - Country:US
Mailing Address - Phone:518-755-2130
Mailing Address - Fax:
Practice Address - Street 1:3624 MARKET ST STE 205
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-2616
Practice Address - Country:US
Practice Address - Phone:215-615-0980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-27
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA23-1352685Medicaid