Provider Demographics
NPI:1851017446
Name:CARLISLE, JESSICA HARLAND (NP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:HARLAND
Last Name:CARLISLE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:MARIE
Other - Last Name:CONDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5171 S COTTONWOOD ST STE 610
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-5741
Mailing Address - Country:US
Mailing Address - Phone:801-507-3630
Mailing Address - Fax:
Practice Address - Street 1:36 S STATE ST FL 22
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-1470
Practice Address - Country:US
Practice Address - Phone:801-703-6721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-14
Last Update Date:2023-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3214414405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner