Provider Demographics
NPI:1093828717
Name:MALONE, JESSICA M (NP)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:M
Last Name:MALONE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:M
Other - Last Name:HANCHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:921 OAK PARK BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-3264
Mailing Address - Country:US
Mailing Address - Phone:805-546-0411
Mailing Address - Fax:805-489-1421
Practice Address - Street 1:77 CASA ST
Practice Address - Street 2:SUITE 103
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-5803
Practice Address - Country:US
Practice Address - Phone:805-546-0411
Practice Address - Fax:805-489-1421
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP 16098363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANP 16098OtherNURSE PRACTICER
CADW461ZMedicare PIN