Provider Demographics
NPI:1417318155
Name:TRAVIS, JESSICA RUTH (CPNP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:RUTH
Last Name:TRAVIS
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:RUTH
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:511 1/2 6TH ST SE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20003-2706
Mailing Address - Country:US
Mailing Address - Phone:201-835-3387
Mailing Address - Fax:
Practice Address - Street 1:111 MICHIGAN AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20010-2916
Practice Address - Country:US
Practice Address - Phone:202-476-3517
Practice Address - Fax:202-476-2490
Is Sole Proprietor?:No
Enumeration Date:2016-03-08
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024173380363LP0200X
DCRN1039813363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics