Provider Demographics
NPI:1700119047
Name:KOURY, JESSICA A (AA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:A
Last Name:KOURY
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:A
Other - Last Name:BALOG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AA
Mailing Address - Street 1:7757 AUBURN RD
Mailing Address - Street 2:UNIT 15
Mailing Address - City:PAINESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44077-9609
Mailing Address - Country:US
Mailing Address - Phone:440-350-0823
Mailing Address - Fax:440-354-7420
Practice Address - Street 1:36000 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-4625
Practice Address - Country:US
Practice Address - Phone:440-350-0832
Practice Address - Fax:440-579-0191
Is Sole Proprietor?:No
Enumeration Date:2009-09-17
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH67.000157367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3000399Medicaid
OH3000399Medicaid