=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194311837
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA EDWARDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/16/2020
-----------------------------------------------------
Last Update Date | 12/16/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 109 W NORTH ST
-----------------------------------------------------
City | PLEASANT HILL
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45359-8042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-621-5163
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6655 WESTFALL RD
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45331-9244
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-621-5163
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 374U00000X
-----------------------------------------------------
Taxonomy Name | Home Health Aide
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------