Provider Demographics
NPI:1114584802
Name:BLACKWILL, JESSICA (APRN)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BLACKWILL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 W D AVE
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:KS
Mailing Address - Zip Code:67068-1266
Mailing Address - Country:US
Mailing Address - Phone:620-532-0295
Mailing Address - Fax:855-483-0002
Practice Address - Street 1:750 W D AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:KS
Practice Address - Zip Code:67068-1266
Practice Address - Country:US
Practice Address - Phone:620-532-0295
Practice Address - Fax:855-483-0002
Is Sole Proprietor?:No
Enumeration Date:2019-05-29
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS13-131277-101163W00000X
KS53-78792-101363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS30003916630006Medicaid
KS201243020AMedicaid