Provider Demographics
NPI:1578709788
Name:CLOUGH, JESSICA LYNNE (CRNA)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:LYNNE
Last Name:CLOUGH
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LYNNE
Other - Last Name:O'BRIEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:789 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:NH
Mailing Address - Zip Code:03820-2526
Mailing Address - Country:US
Mailing Address - Phone:603-609-6819
Mailing Address - Fax:
Practice Address - Street 1:789 CENTRAL AVE.
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:NH
Practice Address - Zip Code:03820-2526
Practice Address - Country:US
Practice Address - Phone:603-609-6819
Practice Address - Fax:603-609-6821
Is Sole Proprietor?:No
Enumeration Date:2008-12-18
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH046604-23367500000X, 367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3082050Medicaid