Provider Demographics
NPI:1710596366
Name:ANDERSON, JESSICA NICOLE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:NICOLE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 MIDDLE RD
Mailing Address - Street 2:
Mailing Address - City:PRESTON
Mailing Address - State:CT
Mailing Address - Zip Code:06365-8207
Mailing Address - Country:US
Mailing Address - Phone:443-262-5898
Mailing Address - Fax:
Practice Address - Street 1:29 MIDDLE RD
Practice Address - Street 2:
Practice Address - City:PRESTON
Practice Address - State:CT
Practice Address - Zip Code:06365-8207
Practice Address - Country:US
Practice Address - Phone:443-262-5898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-29
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RNGroup - Single Specialty