Provider Demographics
NPI:1609217876
Name:ENTREKIN, JESSICA (CRNP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:ENTREKIN
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 1:400 WHITESPORT DR SW
Mailing Address - Street 2:SUITE 103
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-6452
Mailing Address - Country:US
Mailing Address - Phone:256-880-0455
Mailing Address - Fax:
Practice Address - Street 1:400 WHITESPORT DR SW
Practice Address - Street 2:SUITE 103
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-6452
Practice Address - Country:US
Practice Address - Phone:256-880-0455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-16
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AL1-122465363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program