Provider Demographics
NPI:1457639403
Name:GOOD, JESSICA FAY (CNM, ARNP)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:FAY
Last Name:GOOD
Suffix:
Gender:F
Credentials:CNM, ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12221 RENFERT WAY
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78758-5444
Mailing Address - Country:US
Mailing Address - Phone:512-425-3825
Mailing Address - Fax:
Practice Address - Street 1:975 RYLAND ST
Practice Address - Street 2:STE 105
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-1667
Practice Address - Country:US
Practice Address - Phone:775-982-5640
Practice Address - Fax:775-982-5641
Is Sole Proprietor?:No
Enumeration Date:2011-07-25
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACNM0556367A00000X
NVAPN001446363LX0001X
TXAP128016367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1457639403Medicaid
12428218OtherCAQH