Provider Demographics
NPI:1023412079
Name:BOSTATER, JESSICA L (CPNP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:BOSTATER
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:L
Other - Last Name:VILLHAUER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:970 W WOOSTER ST RM 130
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402-2652
Mailing Address - Country:US
Mailing Address - Phone:419-352-6890
Mailing Address - Fax:
Practice Address - Street 1:970 W WOOSTER ST RM 130
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402-2652
Practice Address - Country:US
Practice Address - Phone:419-352-6890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-20
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.16495-NP363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0176546Medicaid