=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144718636
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSIE KICHIGIN CNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/30/2018
-----------------------------------------------------
Last Update Date | 03/09/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 THOMAS LANE SUITE A3
-----------------------------------------------------
City | DUBLIN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43016-9600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-566-2500
-----------------------------------------------------
Fax | 614-533-0335
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 7527
-----------------------------------------------------
City | DUBLIN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43017-0727
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-788-6010
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | APRN.CNP.022537
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------