Healthcare Provider Details

I. General information

NPI: 1023417839
Provider Name (Legal Business Name): JESSIKA LAUREN BASS STNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2014
Last Update Date: 06/20/2023
Certification Date: 06/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1118 PENDLETON ST STE 440
CINCINNATI OH
45202-8805
US

IV. Provider business mailing address

1118 PENDLETON ST STE 440
CINCINNATI OH
45202-8805
US

V. Phone/Fax

Practice location:
  • Phone: 513-824-2065
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.2207828
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: