Provider Demographics
NPI:1174873103
Name:LUCKENBILL, JESSICA G (PA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:G
Last Name:LUCKENBILL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9000 N MAIN ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ENGLEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45415-1180
Mailing Address - Country:US
Mailing Address - Phone:937-836-5555
Mailing Address - Fax:937-836-7518
Practice Address - Street 1:9000 N MAIN ST
Practice Address - Street 2:SUITE 200
Practice Address - City:ENGLEWOOD
Practice Address - State:OH
Practice Address - Zip Code:45415-1180
Practice Address - Country:US
Practice Address - Phone:937-836-5555
Practice Address - Fax:937-836-7518
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-18
Last Update Date:2015-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.003591363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0074453Medicaid
OH0074453Medicaid
OHH134251Medicare PIN