Provider Demographics
NPI:1326643693
Name:SMALL, JESSICA (FNP)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:
Last Name:SMALL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2530 86TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-9672
Mailing Address - Country:US
Mailing Address - Phone:253-380-2679
Mailing Address - Fax:
Practice Address - Street 1:21 NIEDERMAN RD
Practice Address - Street 2:
Practice Address - City:OAKVILLE
Practice Address - State:WA
Practice Address - Zip Code:98568-8904
Practice Address - Country:US
Practice Address - Phone:360-273-5504
Practice Address - Fax:360-273-7217
Is Sole Proprietor?:No
Enumeration Date:2020-12-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61112984207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine