Provider Demographics
NPI:1053663880
Name:BACON, JESSICA A (CNM)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:A
Last Name:BACON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 SOUTHWOOD DR
Mailing Address - Street 2:DARTMOUTH HITCHCOCK - OB/GYN
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03063
Mailing Address - Country:US
Mailing Address - Phone:603-577-3407
Mailing Address - Fax:
Practice Address - Street 1:2300 SOUTHWOOD DR
Practice Address - Street 2:DARTMOUTH HITCHCOCK - OB/GYN
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03063
Practice Address - Country:US
Practice Address - Phone:603-577-3407
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-03
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH12100354367A00000X
NH048175-23367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH1578854287OtherGROUP NPI
NH3081928Medicaid