Provider Demographics
NPI:1184105710
Name:QUALLS, JESSICA (CNM)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:QUALLS
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 S HIGH ST
Mailing Address - Street 2:
Mailing Address - City:ARCANUM
Mailing Address - State:OH
Mailing Address - Zip Code:45304-1212
Mailing Address - Country:US
Mailing Address - Phone:937-417-6238
Mailing Address - Fax:
Practice Address - Street 1:310 S HIGH ST
Practice Address - Street 2:
Practice Address - City:ARCANUM
Practice Address - State:OH
Practice Address - Zip Code:45304-1212
Practice Address - Country:US
Practice Address - Phone:937-417-6238
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-22
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH04411176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife