Provider Demographics
NPI:1396409488
Name:HAUCK, JESSICA GRANT (APRN)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:GRANT
Last Name:HAUCK
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 1:114 LAKE SHORE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH HAMILTON
Mailing Address - State:MA
Mailing Address - Zip Code:01982-2604
Mailing Address - Country:US
Mailing Address - Phone:508-284-9937
Mailing Address - Fax:
Practice Address - Street 1:114 LAKE SHORE AVE
Practice Address - Street 2:
Practice Address - City:SOUTH HAMILTON
Practice Address - State:MA
Practice Address - Zip Code:01982-2604
Practice Address - Country:US
Practice Address - Phone:508-284-9937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-26
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2266142363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily