Provider Demographics
NPI:1851162614
Name:MCMILLAN, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MCMILLAN
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 1:420 WOLLARD BLVD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:MO
Mailing Address - Zip Code:64085-1974
Mailing Address - Country:US
Mailing Address - Phone:816-470-2131
Mailing Address - Fax:
Practice Address - Street 1:420 WOLLARD BLVD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:MO
Practice Address - Zip Code:64085-1974
Practice Address - Country:US
Practice Address - Phone:816-470-2131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-10
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024000811363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty