Provider Demographics
NPI:1962154559
Name:DECKER, JESSICA C (NP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:C
Last Name:DECKER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JESSIE
Other - Middle Name:C
Other - Last Name:DECKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:3131 NEWMARK DR STE 220
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-5400
Mailing Address - Country:US
Mailing Address - Phone:937-438-8910
Mailing Address - Fax:
Practice Address - Street 1:3535 SOUTHERN BLVD
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-1221
Practice Address - Country:US
Practice Address - Phone:937-395-8166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-25
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.361849163WE0003X
OH2021185662363LF0000X
OHAPRN.CNP.0030908363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WE0003XNursing Service ProvidersRegistered NurseEmergency
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily