Provider Demographics
NPI:1689007924
Name:WISOCKY, JESSICA L (APRN)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:WISOCKY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:97 CENTRAL ST STE 303
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01852-1931
Mailing Address - Country:US
Mailing Address - Phone:978-487-6783
Mailing Address - Fax:978-226-4532
Practice Address - Street 1:500 MERRIMACK ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01843-1981
Practice Address - Country:US
Practice Address - Phone:978-557-8900
Practice Address - Fax:978-557-8859
Is Sole Proprietor?:No
Enumeration Date:2013-08-09
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH076676-23363LF0000X
MARN2276918363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1100980411AMedicaid
NH3111245Medicaid