Provider Demographics
NPI:1780946343
Name:BASS, JESSIE L (LPN)
Entity type:Individual
Prefix:MRS
First Name:JESSIE
Middle Name:L
Last Name:BASS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 CHERRY HILL RD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44907-2128
Mailing Address - Country:US
Mailing Address - Phone:419-961-6759
Mailing Address - Fax:
Practice Address - Street 1:180 CHERRY HILL RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44907-2128
Practice Address - Country:US
Practice Address - Phone:419-961-6759
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-11
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.146478-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse