Provider Demographics
NPI:1497486567
Name:WHITE, JALISA (NNP)
Entity Type:Individual
Prefix:
First Name:JALISA
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:NNP
Other - Prefix:
Other - First Name:JALISA
Other - Middle Name:
Other - Last Name:BRICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:612 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:KS
Mailing Address - Zip Code:66111-1393
Mailing Address - Country:US
Mailing Address - Phone:913-309-9281
Mailing Address - Fax:
Practice Address - Street 1:612 S 6TH ST
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:KS
Practice Address - Zip Code:66111-1393
Practice Address - Country:US
Practice Address - Phone:913-309-9281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-21
Last Update Date:2022-10-31
Deactivation Date:2022-07-08
Deactivation Code:
Reactivation Date:2022-10-11
Provider Licenses
StateLicense IDTaxonomies
KS13-131827-041163WN0002X
KS53-81350-041363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical CareGroup - Single Specialty
No163WN0002XNursing Service ProvidersRegistered NurseNeonatal Intensive CareGroup - Single Specialty