Healthcare Provider Details

I. General information

NPI: 1053867390
Provider Name (Legal Business Name): JESSICA A. ROLFES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2016
Last Update Date: 06/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 DOWELL AVE
BELLEFONTAINE OH
43311
US

IV. Provider business mailing address

118 DOWELL AVE
BELLEFONTAINE OH
43311-2305
US

V. Phone/Fax

Practice location:
  • Phone: 937-593-5437
  • Fax: 937-593-0110
Mailing address:
  • Phone: 937-593-5437
  • Fax: 937-593-0110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberCOA.19204-NP
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAPRN.CNP.19204
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: