Provider Demographics
NPI:1316572266
Name:CLEARY, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:CLEARY
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 1:75 S WYOMING AVE
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18704-3103
Mailing Address - Country:US
Mailing Address - Phone:570-704-4233
Mailing Address - Fax:
Practice Address - Street 1:75 S WYOMING AVE
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18704-3103
Practice Address - Country:US
Practice Address - Phone:570-704-4233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-10
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP022437363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily