Provider Demographics
NPI:1659981959
Name:FUQUA, JESSICA LEIGH (NP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEIGH
Last Name:FUQUA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29653 ANCHOR BLVD
Mailing Address - Street 2:
Mailing Address - City:DAPHNE
Mailing Address - State:AL
Mailing Address - Zip Code:36526
Mailing Address - Country:US
Mailing Address - Phone:251-625-6896
Mailing Address - Fax:
Practice Address - Street 1:6701 AIRPORT BLVD.
Practice Address - Street 2:'B' BLDG., 'T' LEVEL
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608
Practice Address - Country:US
Practice Address - Phone:251-625-6896
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-03
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-100344363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL255792Medicaid
ALA10621AOtherMEDICARE PTAN
ALP02566936OtherRAILROAD MEDICARE
AL257688Medicaid