Provider Demographics
NPI:1154744852
Name:JESSOP, VICKI L (NP)
Entity type:Individual
Prefix:
First Name:VICKI
Middle Name:L
Last Name:JESSOP
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 23RD ST
Mailing Address - Street 2:PAIN MEDICINE
Mailing Address - City:CUYAHOGA FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44223-1404
Mailing Address - Country:US
Mailing Address - Phone:330-971-7246
Mailing Address - Fax:330-971-7256
Practice Address - Street 1:1900 23RD ST
Practice Address - Street 2:PAIN MEDICINE
Practice Address - City:CUYAHOGA FALLS
Practice Address - State:OH
Practice Address - Zip Code:44223-1404
Practice Address - Country:US
Practice Address - Phone:330-971-7246
Practice Address - Fax:330-971-7256
Is Sole Proprietor?:No
Enumeration Date:2014-01-31
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.15613-NP363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0098159Medicaid