=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033174982
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK D. JESSEN M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/20/2006
-----------------------------------------------------
Last Update Date | 07/18/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1326 ANDREA ST
-----------------------------------------------------
City | BOWLING GREEN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42104-3334
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-781-1588
-----------------------------------------------------
Fax | 270-781-1598
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1326 ANDREA ST
-----------------------------------------------------
City | BOWLING GREEN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42104-3334
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-781-1588
-----------------------------------------------------
Fax | 270-781-1598
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 29379
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------