Healthcare Provider Details

I. General information

NPI: 1679573034
Provider Name (Legal Business Name): TIMOTHY A JESSIE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 05/02/2025
Certification Date: 05/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 N TOWNLINE RD STE 101
LAGRANGE IN
46761-1325
US

IV. Provider business mailing address

11109 PARKVIEW PLAZA DR # 117
FORT WAYNE IN
46845-1701
US

V. Phone/Fax

Practice location:
  • Phone: 260-463-9335
  • Fax: 260-463-9334
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD2020-0191
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number35083403
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number200501327
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberD73747
License Number StateMD
# 5
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number32580
License Number StateKS
# 6
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number01076415A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: