Provider Demographics
NPI:1396105284
Name:LOTZ, JESSIE (LPN)
Entity type:Individual
Prefix:
First Name:JESSIE
Middle Name:
Last Name:LOTZ
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17506 FREYMUTH RD
Mailing Address - Street 2:
Mailing Address - City:WAPAKONETA
Mailing Address - State:OH
Mailing Address - Zip Code:45895-9014
Mailing Address - Country:US
Mailing Address - Phone:567-356-0419
Mailing Address - Fax:
Practice Address - Street 1:17506 FREYMUTH RD
Practice Address - Street 2:
Practice Address - City:WAPAKONETA
Practice Address - State:OH
Practice Address - Zip Code:45895-9014
Practice Address - Country:US
Practice Address - Phone:567-356-0419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-04
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.156715-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse