Provider Demographics
NPI:1003397605
Name:SCOVILLE, JESSICA (CSFA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:SCOVILLE
Suffix:
Gender:F
Credentials:CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1710 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:COZAD
Mailing Address - State:NE
Mailing Address - Zip Code:69130-1660
Mailing Address - Country:US
Mailing Address - Phone:308-440-1101
Mailing Address - Fax:
Practice Address - Street 1:804 22ND AVE
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68845-2206
Practice Address - Country:US
Practice Address - Phone:308-440-1101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-22
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE40246ZC0007X
363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant