Provider Demographics
NPI:1073980611
Name:LATHAM, JESSICA LYNN (AGNP-C)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:LYNN
Last Name:LATHAM
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:LYNN
Other - Last Name:LATHAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:AGNP-C
Mailing Address - Street 1:11133 DUNN RD
Mailing Address - Street 2:SUITE 2335
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63136-6119
Mailing Address - Country:US
Mailing Address - Phone:314-653-5007
Mailing Address - Fax:314-653-4149
Practice Address - Street 1:1133 DUNN RD
Practice Address - Street 2:SUITE 2335
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-6119
Practice Address - Country:US
Practice Address - Phone:314-653-5007
Practice Address - Fax:314-653-5007
Is Sole Proprietor?:No
Enumeration Date:2015-08-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060472784146D00000X
MO2010040204163WE0003X
MO2015028258363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant
No163WE0003XNursing Service ProvidersRegistered NurseEmergency
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1073980611Medicaid