Provider Demographics
NPI:1184257818
Name:PRICE, JESSICKA LYNN (FNP)
Entity type:Individual
Prefix:
First Name:JESSICKA
Middle Name:LYNN
Last Name:PRICE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:599 MARIE ST
Mailing Address - Street 2:
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202-1656
Mailing Address - Country:US
Mailing Address - Phone:208-220-3756
Mailing Address - Fax:
Practice Address - Street 1:1155 YELLOWSTONE AVE STE D
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4369
Practice Address - Country:US
Practice Address - Phone:208-637-9610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-21
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDTEMP63583363LF0000X
NV827657363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily