Basic Information
| Provider Information | |||||||||
| NPI: | 1790750446 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WELLS | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 636643 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452636643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409893801 | ||||||||
| FaxNumber: | 4409600264 | ||||||||
| Practice Location | |||||||||
| Address1: | 221 W 21ST ST | ||||||||
| Address2: | STE 1 | ||||||||
| City: | LORAIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440524754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402330138 | ||||||||
| FaxNumber: | 4402331051 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2006 | ||||||||
| LastUpdateDate: | 01/28/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | 35084345 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 2472935 | 05 | OH | MEDICAID | 3025372 | 05 | OH | MEDICAID | 0236248 | 05 | OH | MEDICAID |