Provider Demographics
NPI:1578852133
Name:EDMONDSON, JESSICA LEE GILLILAN (CRNP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEE GILLILAN
Last Name:EDMONDSON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1153 AL HIGHWAY 205
Mailing Address - Street 2:
Mailing Address - City:BOAZ
Mailing Address - State:AL
Mailing Address - Zip Code:35956-5413
Mailing Address - Country:US
Mailing Address - Phone:256-572-2791
Mailing Address - Fax:
Practice Address - Street 1:1600 7TH AVE S BLDG SUITE516
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35233
Practice Address - Country:US
Practice Address - Phone:205-638-9781
Practice Address - Fax:205-975-7051
Is Sole Proprietor?:No
Enumeration Date:2011-04-05
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-105098363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics