Healthcare Provider Details

I. General information

NPI: 1245649615
Provider Name (Legal Business Name): JODI MICSKY CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2014
Last Update Date: 10/11/2024
Certification Date: 10/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 E WESTERN RESERVE RD
POLAND OH
44514-3358
US

IV. Provider business mailing address

PO BOX 636988
CINCINNATI OH
45263-6988
US

V. Phone/Fax

Practice location:
  • Phone: 330-726-3204
  • Fax: 330-729-9316
Mailing address:
  • Phone: 888-940-2722
  • Fax: 513-632-8898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAPRN.CNP.16119
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAPRN.CNP.16119
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: