Healthcare Provider Details

I. General information

NPI: 1679511976
Provider Name (Legal Business Name): JESSICA W MADDEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 04/15/2020
Certification Date: 04/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31731 LAKE SHORE BLVD
WILLOWICK OH
44095-3529
US

IV. Provider business mailing address

31731 LAKE SHORE BLVD
WILLOWICK OH
44095-3529
US

V. Phone/Fax

Practice location:
  • Phone: 216-313-2016
  • Fax:
Mailing address:
  • Phone: 216-313-2016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number35.087675
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: