Provider Demographics
NPI:1033768577
Name:FOX, JESSIE NICOLE
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:NICOLE
Last Name:FOX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3988
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-3988
Mailing Address - Country:US
Mailing Address - Phone:618-457-5200
Mailing Address - Fax:618-529-0586
Practice Address - Street 1:2808 OUTER DR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-5207
Practice Address - Country:US
Practice Address - Phone:618-993-3817
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-07
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209020010363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner