MEDICARE: MRS. JESSICA LEE GENTRY RN, BSN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	364927	OH

General Provider Information

NPI Number	:	1609743756
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JESSICA LEE GENTRY RN, BSN

Provider Business Mailing Address
First Line	:	8126 DAYTON SPRINGFIELD RD
Second Line	:
City	:	FAIRBORN
State	:	OH
Zip	:	45324-1909
Country	:	US
Telephone Number	:	937-347-7124
Fax Number	:

Provider Business Practice Location Address
First Line	:	8126 DAYTON SPRINGFIELD RD
Second Line	:
City	:	FAIRBORN
State	:	OH
Zip	:	45324-1909
Country	:	US
Telephone Number	:	937-347-7124
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/22/2025
Last Update Date	:	10/22/2025

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