Provider Demographics
NPI:1407449663
Name:BACON, JESSICA (FNP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BACON
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 1:10 POPE AVE # 5566
Mailing Address - Street 2:
Mailing Address - City:HILTON HEAD
Mailing Address - State:SC
Mailing Address - Zip Code:29928-4719
Mailing Address - Country:US
Mailing Address - Phone:843-785-7786
Mailing Address - Fax:
Practice Address - Street 1:10 POPE AVE # 5566
Practice Address - Street 2:
Practice Address - City:HILTON HEAD
Practice Address - State:SC
Practice Address - Zip Code:29928-4719
Practice Address - Country:US
Practice Address - Phone:843-785-7786
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-18
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN292014363LF0000X
SC24873363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily