Provider Demographics
NPI:1275101610
Name:MCCULLOCH, JESSICA (FNP-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MCCULLOCH
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-6236
Mailing Address - Country:US
Mailing Address - Phone:801-505-0821
Mailing Address - Fax:801-505-0803
Practice Address - Street 1:57 N 775 E
Practice Address - Street 2:
Practice Address - City:TREMONTON
Practice Address - State:UT
Practice Address - Zip Code:84337-4103
Practice Address - Country:US
Practice Address - Phone:435-915-6262
Practice Address - Fax:435-201-8200
Is Sole Proprietor?:No
Enumeration Date:2021-06-13
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10400966-3102163W00000X
UT10400966-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse