Provider Demographics
NPI:1659323541
Name:PEDERSEN, JESSICA LEIGH (ARNP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEIGH
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 MAINE ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66044-1360
Mailing Address - Country:US
Mailing Address - Phone:785-505-3114
Mailing Address - Fax:785-505-3113
Practice Address - Street 1:325 MAINE ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66044-1360
Practice Address - Country:US
Practice Address - Phone:785-505-3114
Practice Address - Fax:785-505-3113
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS45754363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200356810AMedicaid
KS033E223DMedicare ID - Type Unspecified
KS200356810AMedicaid