Provider Demographics
NPI:1649407040
Name:HENRY, JESSE (FNP)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:HENRY
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1252 N 22ND ST UNIT B
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82072-5306
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1252 N 22ND ST UNIT B
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82072-5306
Practice Address - Country:US
Practice Address - Phone:307-745-3704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-12
Last Update Date:2009-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY23263.1005363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily