Provider Demographics
NPI:1063071520
Name:ULLERY, JESSICA LYNN (CNP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:ULLERY
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3535 PENTAGON BLVD STE 220
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45431-1705
Mailing Address - Country:US
Mailing Address - Phone:937-429-7350
Mailing Address - Fax:937-431-2623
Practice Address - Street 1:3535 PENTAGON BLVD STE 220
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45431-1705
Practice Address - Country:US
Practice Address - Phone:937-429-7350
Practice Address - Fax:937-431-2623
Is Sole Proprietor?:No
Enumeration Date:2019-06-10
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.024578363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0353060Medicaid