Basic Information
Provider Information | |||||||||
NPI: | 1295125342 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MOSSOR | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | LYNN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | APRN-CNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GILL | ||||||||
OtherFirstName: | JENNIFER | ||||||||
OtherMiddleName: | LYNN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | CNP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 700 ACKERMAN RD STE 570 | ||||||||
Address2: |   | ||||||||
City: | COLUMBUS | ||||||||
State: | OH | ||||||||
PostalCode: | 432021579 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6142933230 | ||||||||
FaxNumber: | 6142934030 | ||||||||
Practice Location | |||||||||
Address1: | 181 TAYLOR AVE STE 1102 | ||||||||
Address2: |   | ||||||||
City: | COLUMBUS | ||||||||
State: | OH | ||||||||
PostalCode: | 432031779 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6142933230 | ||||||||
FaxNumber: | 6142934030 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/28/2015 | ||||||||
LastUpdateDate: | 12/17/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | APRN.CNP.021157 | OH | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 363LP2300X | APRN.CNP.021157 | OH | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
ID Information
ID | Type | State | Issuer | Description | 0263073 | 05 | OH |   | MEDICAID |