Provider Demographics
NPI:1558979658
Name:RAEBEL, JESSICA ANNE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANNE
Last Name:RAEBEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2509 WYNTERHALL RD SE
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35803-2903
Mailing Address - Country:US
Mailing Address - Phone:256-541-1331
Mailing Address - Fax:
Practice Address - Street 1:5959 PARK AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-5200
Practice Address - Country:US
Practice Address - Phone:901-765-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-15
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TN28111367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program