Healthcare Provider Details

I. General information

NPI: 1306295423
Provider Name (Legal Business Name): MISS JELISSA STURDIVANT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2016
Last Update Date: 09/17/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3650 MUDDY CREEK RD STE 100
CINCINNATI OH
45238-2058
US

IV. Provider business mailing address

1044 SPRINGBROOK DR
CINCINNATI OH
45224-1658
US

V. Phone/Fax

Practice location:
  • Phone: 513-347-0375
  • Fax:
Mailing address:
  • Phone: 513-704-8314
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: