Provider Demographics
NPI:1679573034
Name:JESSIE, TIMOTHY A (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:A
Last Name:JESSIE
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:207 N TOWNLINE RD STE 101
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:IN
Practice Address - Zip Code:46761-1325
Practice Address - Country:US
Practice Address - Phone:260-463-9335
Practice Address - Fax:260-463-9334
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2020-0191208600000X
IN01076415A208600000X
NC200501327208600000X
KS32580208600000X
OH35083403208600000X
MDD73747208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM69777233Medicaid
OH2501902Medicaid
OH24-46612OtherUHC
OHP00144471OtherRRMC
OH2501902Medicaid