Provider Demographics
NPI:1962786095
Name:EVANS, JESSICA LYN (CNM)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:LYN
Last Name:EVANS
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:MISS
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:MOON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 633448
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-3448
Mailing Address - Country:US
Mailing Address - Phone:513-853-4731
Mailing Address - Fax:513-569-6117
Practice Address - Street 1:3219 CLIFTON AVE.,
Practice Address - Street 2:STE. 210
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45220-3041
Practice Address - Country:US
Practice Address - Phone:513-751-5900
Practice Address - Fax:513-487-4590
Is Sole Proprietor?:No
Enumeration Date:2011-10-07
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.12756367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0056363Medicaid
OH0056363Medicaid