Provider Demographics
NPI:1700776770
Name:HODGE, JESSICA MARIE (AGACNP-BC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:HODGE
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:MARIE
Other - Last Name:DIAMOND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:123 HIDEAWAY LOOP
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92692-5979
Mailing Address - Country:US
Mailing Address - Phone:949-560-1889
Mailing Address - Fax:
Practice Address - Street 1:123 HIDEAWAY LOOP
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92692-5979
Practice Address - Country:US
Practice Address - Phone:949-560-1889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-09
Last Update Date:2025-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95033267363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care