MEDICARE: JESSICA RAE BUSSEY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	275312	OH
2	363LF0000X	Family Nurse Practitioner	025701	OH

General Provider Information

NPI Number	:	1801399415
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA RAE BUSSEY

Provider Business Mailing Address
First Line	:	407 W MAPLE ST
Second Line	:
City	:	NORTH CANTON
State	:	OH
Zip	:	44720-2719
Country	:	US
Telephone Number	:	336-682-8051
Fax Number	:	234-867-7766

Provider Business Practice Location Address
First Line	:	500 PORTAGE LAKES DR
Second Line	:
City	:	COVENTRY TOWNSHIP
State	:	OH
Zip	:	44319-2299
Country	:	US
Telephone Number	:	234-867-6626
Fax Number	:	234-867-7766

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/10/2018
Last Update Date	:	06/12/2025

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Directions to “ JESSICA RAE BUSSEY ” Practice Location

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