Provider Demographics
NPI:1164140281
Name:ANDERSON, JESSICA MICHELLE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MICHELLE
Last Name:ANDERSON
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 1:1308 W LYDIA ST
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-2181
Mailing Address - Country:US
Mailing Address - Phone:760-497-0753
Mailing Address - Fax:
Practice Address - Street 1:1308 W LYDIA ST
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-2181
Practice Address - Country:US
Practice Address - Phone:760-497-0753
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-15
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID70287207Q00000X, 363L00000X
CA644524207Q00000X
CA95015168363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine