Provider Demographics
NPI:1851774905
Name:WIRTH, JESSICA (APRN,CNP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:WIRTH
Suffix:
Gender:F
Credentials:APRN,CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 ST FRANCIS DR
Mailing Address - Street 2:
Mailing Address - City:BRECKENRIDGE
Mailing Address - State:MN
Mailing Address - Zip Code:56520-1025
Mailing Address - Country:US
Mailing Address - Phone:218-643-0747
Mailing Address - Fax:218-643-0748
Practice Address - Street 1:2400 ST FRANCIS DR
Practice Address - Street 2:
Practice Address - City:BRECKENRIDGE
Practice Address - State:MN
Practice Address - Zip Code:56520-1025
Practice Address - Country:US
Practice Address - Phone:218-643-0747
Practice Address - Fax:218-643-0748
Is Sole Proprietor?:No
Enumeration Date:2015-07-08
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR-187957-3363LF0000X
NDR44952363LF0000X
MNCNP 3968363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1472569Medicaid