Provider Demographics
NPI:1891561015
Name:GOEBEL, JESSICA DIANE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:DIANE
Last Name:GOEBEL
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 1:18408 WAYNE ROUTE D
Mailing Address - Street 2:
Mailing Address - City:WAPPAPELLO
Mailing Address - State:MO
Mailing Address - Zip Code:63966-8659
Mailing Address - Country:US
Mailing Address - Phone:573-222-8676
Mailing Address - Fax:
Practice Address - Street 1:18408 WAYNE ROUTE D
Practice Address - Street 2:
Practice Address - City:WAPPAPELLO
Practice Address - State:MO
Practice Address - Zip Code:63966-8659
Practice Address - Country:US
Practice Address - Phone:573-222-8676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-29
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013034134164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse