Provider Demographics
NPI:1912376740
Name:FUNK, JESSICA (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:
Last Name:FUNK
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:MISS
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:HALE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1515 NE LAWRIE TATUM RD
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73507-3099
Mailing Address - Country:US
Mailing Address - Phone:580-354-5400
Mailing Address - Fax:580-354-5409
Practice Address - Street 1:1515 NE LAWRIE TATUM RD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73507-3099
Practice Address - Country:US
Practice Address - Phone:580-354-5400
Practice Address - Fax:580-354-5409
Is Sole Proprietor?:No
Enumeration Date:2015-09-23
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK106355363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner