Provider Demographics
NPI:1750598074
Name:FANNIN, JESSICA DARLENE (HHA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:DARLENE
Last Name:FANNIN
Suffix:
Gender:F
Credentials:HHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4218 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:NEW BOSTON
Mailing Address - State:OH
Mailing Address - Zip Code:45662-5103
Mailing Address - Country:US
Mailing Address - Phone:740-456-0392
Mailing Address - Fax:
Practice Address - Street 1:4218 CEDAR ST
Practice Address - Street 2:
Practice Address - City:NEW BOSTON
Practice Address - State:OH
Practice Address - Zip Code:45662-5103
Practice Address - Country:US
Practice Address - Phone:740-456-0392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRU135227374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide