Provider Demographics
NPI:1922656040
Name:WEAVER, JESSICA (BSN, RN)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:WEAVER
Suffix:
Gender:F
Credentials:BSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:919 W BARROW DR
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85225-2151
Mailing Address - Country:US
Mailing Address - Phone:480-477-4236
Mailing Address - Fax:480-687-2919
Practice Address - Street 1:919 W BARROW DR
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85225-2151
Practice Address - Country:US
Practice Address - Phone:480-477-4236
Practice Address - Fax:480-687-2919
Is Sole Proprietor?:No
Enumeration Date:2019-09-02
Last Update Date:2019-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN177767163WH0200X
AZALM-011711376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376G00000XNursing Service Related ProvidersNursing Home Administrator
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ82-4751447Other82-4751447