Provider Demographics
NPI:1306295423
Name:STURDIVANT, JELISSA
Entity type:Individual
Prefix:MISS
First Name:JELISSA
Middle Name:
Last Name:STURDIVANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1044 SPRINGBROOK DR
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45224-1658
Mailing Address - Country:US
Mailing Address - Phone:513-704-8314
Mailing Address - Fax:
Practice Address - Street 1:3650 MUDDY CREEK RD STE 100
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45238-2058
Practice Address - Country:US
Practice Address - Phone:513-347-0375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-09
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No374U00000XNursing Service Related ProvidersHome Health Aide