Healthcare Provider Details

I. General information

NPI: 1962786095
Provider Name (Legal Business Name): JESSICA LYN EVANS CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS JESSICA MOON

II. Dates (important events)

Enumeration Date: 10/07/2011
Last Update Date: 04/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3219 CLIFTON AVE., STE. 210
CINCINNATI OH
45220-3041
US

IV. Provider business mailing address

PO BOX 633448
CINCINNATI OH
45263-3448
US

V. Phone/Fax

Practice location:
  • Phone: 513-751-5900
  • Fax: 513-487-4590
Mailing address:
  • Phone: 513-853-4731
  • Fax: 513-569-6117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberCOA.12756
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: