Provider Demographics
NPI:1700130564
Name:CHEADLE, JESSICA L (C-NP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:CHEADLE
Suffix:
Gender:F
Credentials:C-NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5053 WOOSTER RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45226-2326
Mailing Address - Country:US
Mailing Address - Phone:513-751-2273
Mailing Address - Fax:513-751-1848
Practice Address - Street 1:4777 E GALBRAITH RD STE 320
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45236-2725
Practice Address - Country:US
Practice Address - Phone:513-751-2273
Practice Address - Fax:513-751-1848
Is Sole Proprietor?:No
Enumeration Date:2012-11-01
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71007486A363L00000X
OH14047-NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0075334Medicaid
KY7100160120Medicaid
IN201132210Medicaid
KY7100160120Medicaid