Provider Demographics
NPI:1710225982
Name:WILLOUGHBY, JESSICA (LM,CPM)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:WILLOUGHBY
Suffix:
Gender:F
Credentials:LM,CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 20TH AVE N LOWR
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33704-3909
Mailing Address - Country:US
Mailing Address - Phone:813-404-7120
Mailing Address - Fax:
Practice Address - Street 1:1405 DR MLK JR ST N
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33704
Practice Address - Country:US
Practice Address - Phone:727-895-2300
Practice Address - Fax:727-895-2375
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-23
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMW289176B00000X
374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No374J00000XNursing Service Related ProvidersDoula