Provider Demographics
NPI:1851573489
Name:GAGNON, JESSICA R (FNP)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:R
Last Name:GAGNON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:R
Other - Last Name:BRESETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:140 ACADEMY ST
Mailing Address - Street 2:
Mailing Address - City:PRESQUE ISLE
Mailing Address - State:ME
Mailing Address - Zip Code:04769-3102
Mailing Address - Country:US
Mailing Address - Phone:207-764-5437
Mailing Address - Fax:207-764-4760
Practice Address - Street 1:140 ACADEMY ST
Practice Address - Street 2:
Practice Address - City:PRESQUE ISLE
Practice Address - State:ME
Practice Address - Zip Code:04769-3102
Practice Address - Country:US
Practice Address - Phone:207-764-5437
Practice Address - Fax:207-764-4760
Is Sole Proprietor?:No
Enumeration Date:2007-12-05
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP81824363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1851573489Medicaid
ME000539102Medicare PIN