Healthcare Provider Details

I. General information

NPI: 1982903027
Provider Name (Legal Business Name): NICOLE RUTH JESSEN MS, ATC, LAT, PES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2011
Last Update Date: 04/17/2023
Certification Date: 04/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2830 NAPOLEON RD
FREMONT OH
43420-9814
US

IV. Provider business mailing address

3218 ELMONT RD APT 2
TOLEDO OH
43615-1478
US

V. Phone/Fax

Practice location:
  • Phone: 419-559-2100
  • Fax:
Mailing address:
  • Phone: 440-554-9285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT9279
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT003428
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberAT.003428
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: