Healthcare Provider Details

I. General information

NPI: 1760817142
Provider Name (Legal Business Name): JESSICA BOKELMAN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA VICK D.O.

II. Dates (important events)

Enumeration Date: 09/04/2013
Last Update Date: 07/26/2023
Certification Date: 07/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 VIOLET RD
CRITTENDEN KY
41030-8956
US

IV. Provider business mailing address

PO BOX 635283
CINCINNATI OH
45263-5283
US

V. Phone/Fax

Practice location:
  • Phone: 859-903-0268
  • Fax: 859-428-1444
Mailing address:
  • Phone: 859-301-4688
  • Fax: 859-301-2607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number04049
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number04049
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: