Provider Demographics
NPI:1417929910
Name:THIBODEAU, JESSICA (APRN, BC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:THIBODEAU
Suffix:
Gender:F
Credentials:APRN, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:LISBON
Mailing Address - State:NH
Mailing Address - Zip Code:03585-6508
Mailing Address - Country:US
Mailing Address - Phone:603-838-8967
Mailing Address - Fax:
Practice Address - Street 1:25 MOUNT EUSTIS RD
Practice Address - Street 2:
Practice Address - City:LITTLETON
Practice Address - State:NH
Practice Address - Zip Code:03561-3712
Practice Address - Country:US
Practice Address - Phone:603-444-2464
Practice Address - Fax:603-444-3441
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0417842305363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30009281Medicaid
NP0607Medicare ID - Type Unspecified