Provider Demographics
NPI:1124353982
Name:BRANDON, JESSICA MARIE (CRNA)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:MARIE
Last Name:BRANDON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11588 TONY MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72701-9357
Mailing Address - Country:US
Mailing Address - Phone:573-683-1280
Mailing Address - Fax:
Practice Address - Street 1:3000 MEDICAL CENTER PKWY
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-3217
Practice Address - Country:US
Practice Address - Phone:479-553-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-13
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009007465363LA2100X
ARC02903367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR180228758Medicaid
431560263OtherTRICARE WEST
MO132680108Medicare PIN